Inaccurate MDS Coding of Major Injury After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to accurately code the Minimum Data Set (MDS) to reflect a resident’s true injury status following a fall. The resident, who had a history of Intellectual Developmental Disability and was assessed on the MDS as rarely or never understood with severe cognitive deficits, experienced a fall on a specified date. Nursing progress notes documented that when staff entered the room, the resident was lying face down with agonal respirations, had a bleeding laceration on the top left of the forehead, slowed respirations, and was fully unconscious. A subsequent late entry nursing note further described bleeding on the left side of the head, abrasions to both upper extremities, and that the resident was unresponsive at that time. Despite these documented clinical findings, the MDS dated for that assessment period was not coded to indicate a major injury under Section J1900C, which includes closed head injury with altered consciousness. During interview and record review, the MDS Coordinator acknowledged that the resident’s condition, including the need for cervical precautions, slowed respirations, head bleeding, and full unconsciousness, met the criteria for a major injury and should have been coded as such. The DON also stated that accurate MDS coding is essential to correctly reflect a resident’s clinical status and to guide care planning and clinical decision making. The facility’s own Resident Assessments policy required that information in MDS assessments consistently reflect information in progress notes, plans of care, and resident observations/interviews, which did not occur in this case.
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