Inaccurate MDS Coding for Restraint Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one resident, resulting in a discrepancy between the MDS and the resident's restraint assessment. Specifically, the quarterly MDS indicated that bed rails were used daily as restraints, while the restraint assessment form completed two days prior documented that no restraints were in use. Staff interviews confirmed that the resident used bilateral side rails to aid in mobility and define bed boundaries, and these were not considered restraints according to facility policy. The MDS nurse acknowledged the inaccurate coding and confirmed that the resident had been assessed for side rail use, but the side rails were not classified as restraints. The resident involved had a diagnosis of Alzheimer's disease and had been admitted to the facility with this condition.