Inaccurate MDS Assessment for Resident with Multiple Falls
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for a resident with a history of falls. The resident, who had diagnoses of hemiplegia and hemiparesis following a stroke, experienced three documented falls after admission. Incident reports and progress notes detailed unwitnessed falls from a wheelchair and bed, with specific dates and circumstances recorded in the resident's medical record. Despite this documentation, the 5-day MDS assessment for the resident was incorrectly coded to indicate that no falls had occurred since admission. The MDS Coordinator/registered nurse acknowledged during an interview that the assessment was inaccurate and that the falls had been missed during the review of risk management reports and progress notes. Facility policy requires that MDS assessments consistently reflect information in progress notes and other records, which was not followed in this instance.