F0641

E

Inaccurate MDS Coding and Missing Discharge Assessment

Cambridge, Maryland Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for multiple residents and did not complete a required discharge assessment for one resident. For one resident, the admission MDS with an assessment reference date (ARD) of 11/3/25 captured only one fall without injury, despite medical record documentation of three falls on 10/28/25, 11/1/25, and 11/2/25. The same MDS coded that the resident did not receive PRN pain medication, although the November 2025 MAR showed administration of Tylenol on 11/2/25. Another resident experienced a fall in the room on 10/23/25 and was found on the floor; a nurse practitioner note documented a mildly displaced fracture of the right humerus, yet the MDS with an ARD of 11/21/25 coded zero falls with major injury. A third resident’s MDS dated 9/19/25 coded a fall with major injury within the lookback period, but the medical record showed that the resident’s right elbow fracture occurred earlier while lifting a 5‑pound weight and was not due to a fall, and that a later fall with an ordered x‑ray did not have confirmed injury because the resident refused the x‑ray.

Additional MDS coding errors were identified for another resident whose November 2025 MAR documented a Tuberculin PPD injection on 11/3/25, which was not captured in Section N0300 (Medications) of the MDS with an ARD of 11/6/25. The facility also failed to complete a required MDS discharge assessment for a resident admitted in May 2025 and discharged in November 2025. The last MDS on file for this resident was a quarterly assessment dated 9/2/25, and there was no subsequent MDS, including no discharge assessment, in the medical record at the time of review. In each case, the MDS Coordinator confirmed the respective coding errors and the absence of the discharge assessment during surveyor interviews.