Failure to Accurately Code Resident Fall on MDS Assessment
Penalty
Summary
The facility failed to accurately code a fall incident on the Minimum Data Set (MDS) for one resident. The resident, who had a history of Paroxysmal Atrial Fibrillation, experienced an unwitnessed fall in her room, as documented in both the Intradisciplinary (IDT) note and a progress note. The fall was not coded on the resident's quarterly MDS assessment, which instead indicated that no fall had occurred since admission or the prior assessment. This omission was confirmed during interviews with the MDS Nurse (MDSN) and the Director of Nursing (DON), both of whom acknowledged that the fall should have been coded according to the Resident Assessment Instrument (RAI) guidelines. The inaccurate coding resulted in the resident's fall not being reflected in the federal database, which is used for care planning and monitoring of fall risks. The resident's care plan had previously identified a risk for falls, but the failure to code the incident on the MDS meant that the assessment did not accurately represent the resident's health status or fall history at the time of the deficiency.