Inaccurate MDS Coding of Resident Fall Event
Penalty
Summary
The facility failed to accurately encode a resident's health status on the Minimum Data Set (MDS) regarding falls. Specifically, a resident with moderate cognitive impairment, as indicated by a Brief Interview of Mental Status score of 10 out of 15, experienced a witnessed fall from a wheelchair in the dining room, resulting in a skin tear to the left elbow. This fall was documented in the resident's AIMS Wellness Event Record and the facility's fall log, but was not reflected in the resident's most recent quarterly MDS assessment, which incorrectly indicated that the resident had not experienced any falls since the last assessment. Interviews with facility staff confirmed the discrepancy. The DON, who reviewed the electronic medical record, acknowledged that the MDS did not accurately reflect the resident's status at the time of assessment, citing the documented fall. The administrator, who had recently taken over MDS responsibilities due to staff turnover, also recognized that the fall may have been missed in the MDS documentation. The resident was unable to recall details of the falls due to cognitive impairment.