Failure to Accurately Code Fall with Injury on MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected their status, specifically by not coding a fall with injury on the admission Minimum Data Set (MDS) assessment. The resident, a male with diagnoses including encephalopathy, intracranial injury with loss of consciousness, and dementia, experienced an unwitnessed fall resulting in a superficial abrasion on the left iliac crest. Despite documentation of the fall and injury in the post-incident assessment and skin check, the MDS assessment completed shortly after the incident recorded the fall as having occurred without injury. Interviews with facility staff, including the MDS Nurse, DON, and Administrator, revealed that the error in the MDS assessment was attributed to the injury not being reflected in the assessment documentation. Staff indicated that care provision was based on physician orders and other documentation rather than the MDS assessment. The facility's policy requires that each resident's medical record accurately represent their experiences and include complete, accurate, and timely documentation.