Inaccurate Resident Assessment Following Fall
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that the assessment for one resident accurately reflected the resident's status. Specifically, the annual Minimum Data Set (MDS) assessment indicated that the resident had sustained a major injury following a fall, as coded in section J1900. However, clinical record review and information submitted to the Department of Health showed that the only observed injury was a 2.5 centimeter laceration to the occiput, which was treated with staples before the resident returned to the facility. During staff interview, it was revealed that the laceration was coded as a major injury solely because it involved the head, despite the absence of other qualifying injuries such as fractures or internal organ damage.