Inaccurate MDS Coding of Resident Fall Events
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of falls for one resident. The resident was admitted to the facility and subsequently experienced a fall from bed, resulting in a significant scalp laceration that required staples and sutures. The annual MDS assessment for this resident indicated both a fall with no injury and a fall with injury since the prior assessment. However, a review of the medical record revealed only one fall with injury during this period. During interviews, the MDS nurse acknowledged that the coding of an additional fall with no injury was an error, explaining that she misread the date on an incident report from the previous year. Both the Director of Nursing and the Administrator confirmed that MDS assessments are expected to be coded accurately.