Failure to Accurately Document Fall in MDS Assessment
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment following a fall for one resident. According to facility policy and federal regulations, residents must be assessed using a comprehensive and standardized process to identify care needs. A resident with multiple diagnoses, including cerebral infarction, Alzheimer's disease, dementia with behaviors, diabetes, osteoarthritis, chronic pain, dysphagia, and muscle weakness, experienced an unwitnessed fall resulting in a head injury. However, review of the quarterly MDS assessment conducted after the fall showed that the incident was not identified or documented, and the assessment incorrectly indicated that the resident had not experienced any falls. The MDS Coordinator confirmed during an interview that the fall was overlooked and not recorded in the assessment.