Inaccurate MDS Assessment Following Resident Fall with Injury
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's health conditions following a fall. A resident with multiple diagnoses, including seizures, muscle weakness, and dementia, experienced a fall resulting in bleeding from the nose, a skin tear above the eyebrow, and was subsequently transferred to the hospital. Hospital records documented significant injuries, including a subdural hematoma, nasal bone fractures, a right femoral neck fracture, and other facial injuries. However, the discharge MDS assessment completed with an Assessment Reference Date (ARD) on the day of the fall indicated only one fall with no injury since admission or prior assessment. Interviews with the MDS Coordinator, DON, and Regional MDS Nurse confirmed that the discharge MDS assessment was inaccurate, as it did not capture the injuries sustained by the resident during the fall. The staff acknowledged that the assessment should have reflected the injuries, but the MDS was completed before all injury information was known. The facility's policy requires that MDS assessments accurately reflect information in the medical record, but this was not followed in this instance.