Inaccurate MDS Coding of Resident Falls
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents with documented falls. For one resident, medical record review showed two falls within the assessment look-back period: one fall without injury and a subsequent fall resulting in a scalp laceration requiring emergency room evaluation and placement of two staples. However, the annual MDS with an assessment reference date of 11/20/25 captured only one fall without injury and did not include the fall with injury. For another resident, records documented two separate falls, both described in change in condition notes as the resident being found on the floor near the bed with no injuries noted, but the MDS with an assessment reference date of 11/21/25 captured only one fall without injury. Additional record reviews identified further inaccuracies in MDS fall coding. One resident had a documented fall where the resident was found kneeling on the floor after attempting to transfer from bed to wheelchair, with no injury noted, yet the MDS with an assessment reference date of 11/18/25 documented no falls. Another resident experienced a fall reported by a housekeeper, where the resident was standing at the end of the bed, began coughing, and then sat on the floor, with no injuries noted; the MDS with an assessment reference date of 1/6/26 also documented no falls for this resident. In each of these cases, the MDS Coordinator confirmed during interview that the falls had not been accurately captured on the MDS assessments, and the Nursing Home Administrator was informed of the concern.
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