Inaccurate MDS Coding of Resident Fall
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status regarding falls. Specifically, a male resident on hospice care with diagnoses including malignant neoplasm of the kidney, muscle wasting, and anxiety experienced a fall in his room while reaching for a blanket. The incident was documented in the facility's risk management system and in progress notes, with no injuries observed and appropriate notifications made to the physician, DON, and responsible party. Interventions, such as adding bed bolsters, were implemented and documented in the care plan. Despite the fall being documented in multiple records and discussed among staff, the resident's subsequent quarterly MDS assessment was coded as having had no falls since the prior assessment. The RNAC responsible for completing the MDS stated that her process for identifying falls included attending interdisciplinary meetings and reviewing risk management reports. However, she acknowledged that she coded the MDS incorrectly, indicating no falls, despite the existence of a risk management report documenting the incident. Interviews with the RNAC, DON, and administrator revealed a belief that the miscoding on the MDS would not impact the resident's care as long as the care plan was accurate and interventions were in place. The facility's policy requires that each resident receives an accurate assessment and that the MDS serves as the clinical basis for care planning and delivery. In this case, the MDS assessment did not accurately reflect the resident's fall history, constituting a deficiency in assessment accuracy.