Inaccurate MDS Assessment Following Resident Fall with Major Injury
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status, specifically for one resident who had experienced a fall resulting in a major injury. The resident, an elderly female with multiple diagnoses including a displaced intertrochanteric fracture of the left femur, vascular dementia, and a history of falling, was readmitted to the facility following a hospital stay. Hospital records indicated that she had sustained a ground-level fall and subsequently underwent surgery to repair a left hip fracture caused by another unwitnessed fall in her room. Upon review, the resident's admission MDS assessment did not indicate that she had a fall resulting in a major injury, despite clear documentation in hospital and facility records. The MDS nurse responsible for completing the assessment acknowledged that she had coded the fall with major injury on the discharge MDS, but did not answer affirmatively to the fall-related questions on the reentry MDS. The nurse stated that these questions should have been answered "yes" and recognized that failing to do so could affect the resident's care plan, as falls not triggered on the MDS for a new resident would not appear as high risk on the care plan. The facility did not have a specific policy for ensuring the accuracy of MDS assessments and instead referred to the Resident Assessment Instrument (RAI) manual for guidance. The RAI manual requires a thorough review of the resident's history, including falls and fractures in the six months prior to admission, using information from the resident, family, transfer records, and medical documentation. In this case, the required information was available but not accurately reflected in the MDS assessment.