Inaccurate MDS Coding for Daily Use of Alarms
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident, resulting in the transmission of inaccurate clinical data to CMS. The resident had dementia, a history of falls, and severe cognitive impairment, and required partial to moderate staff assistance for transfers. A physician order dated 4/30/2024 directed staff to apply both a wheelchair and bed alarm to alert staff when the resident attempted to get up without assistance. The Medication Administration Record for the entire month of December 2025 documented daily use of both a wheelchair and bed alarm for this resident. Despite this, the MDS dated [DATE] did not indicate the resident’s daily use of a bed or wheelchair alarm. During interview, the MDS Assistant stated that MDS coding for alarms is based on the previous seven days of alarm use and confirmed that the resident had used alarms daily during that seven-day lookback period. The MDS Assistant acknowledged that the MDS dated [DATE] was not accurate and stated that the MDS should accurately reflect the resident’s clinical condition and the care they received or required, and that alarms were considered a restraint whose use should be routinely reviewed. The facility’s MDS Coordinator Lead job description required that resident assessments present an accurate reflection of the resident, which was not met in this case.
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