Inaccurate MDS Coding for Falls and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, as identified through medical record review and staff interview during a complaint survey. For one resident, an annual MDS with an assessment reference date (ARD) of 10/1/25 incorrectly coded Section J1800 (Falls) as having no falls in the prior three months, despite a care plan update note documenting an unwitnessed fall on 7/11/25. Another resident’s MDS with an ARD of 8/22/25 coded no falls since the last assessment in Section J1800, even though nursing progress notes and a care plan update documented unwitnessed falls on 7/30/25 and 7/31/25. A subsequent MDS for the same resident also failed to capture a fall that occurred during bathing on 9/15/25. Additional MDS coding errors involved medication use not being captured in Section J0100B and Section N0415 (High-Risk Drug Classes). For one resident, the August 2025 MAR and TAR showed administration of PRN Oxycodone and Bacitracin ointment, but the MDS coded no PRN pain medication use and left the antibiotic field blank. Another resident’s December 2025 MAR documented daily Aspirin (antiplatelet) and nightly Gabapentin (anticonvulsant), yet the corresponding MDS left the antiplatelet and anticonvulsant fields blank. A further resident’s February 2025 MAR showed scheduled Tramadol, an opioid, administered prior to therapy sessions on multiple days, but the MDS with an ARD of 2/14/25 did not code opioid use in Section N0415. The MDS Coordinator (RN #16) confirmed these MDS coding errors during interview.
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