MDS Assessment Failed to Reflect Resident's Fall History After Hospital Re-entry
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status following a hospital re-entry. Specifically, the re-entry MDS assessment did not document a fall that resulted in a fracture, which was the reason for the resident's hospitalization and subsequent return to the facility. The resident, an elderly female with diagnoses including a right humerus fracture, metabolic encephalopathy, and chronic kidney disease, had a documented fall at the facility. This fall was recorded in the care plan and incident report, and was confirmed by both the resident and staff interviews, as well as hospital records. However, the MDS section J1700, which addresses fall history, was inaccurately coded to indicate no falls in the month prior to re-entry. Interviews with facility staff revealed that the LVN responsible for completing the MDS was unaware of the omission, despite having updated the care plan to reflect the fall. The Director of Nursing and the Administrator both acknowledged that the fall should have been documented in the MDS, and that such inaccuracies could lead to missed care. The CMS RAI User's Manual requires that the assessment accurately reflect the resident's status, including any falls in the month preceding entry or re-entry, which was not met in this case.