Inaccurate MDS Assessment Coding for Fall and Pressure Ulcer
Penalty
Summary
The facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for one resident. The resident, who was admitted with a history of dysphagia, aphasia following a stroke, chronic obstructive pulmonary disease, and congestive heart failure, had a documented pressure ulcer on the coccyx and sustained a fall resulting in a skin tear to the right hand shortly after admission. Despite these documented conditions, the 5-day MDS assessment indicated that the resident had no falls since admission and no pressure ulcers. The MDS Coordinator, who completed and signed the assessment, did not accurately code these events, as confirmed by interviews and record reviews. The facility's policy required staff to certify the accuracy of each portion of the MDS, and the CMS RAI Manual provided clear coding instructions for falls and pressure ulcers, which were not followed in this case. Further review of the resident's care plan and progress notes confirmed the presence of a pressure ulcer and a fall, both of which were addressed in care planning and interventions. Interviews with the DON, MDS Coordinator, and Administrator revealed that the MDS Coordinator did not clarify the pressure ulcer information with nursing staff and failed to code the fall, despite being aware of both incidents. The inaccuracy of the MDS assessment had the potential to affect the resident's care and care planning, as the assessment did not reflect the resident's actual status.