Inaccurate MDS Coding of Resident Fall History
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident by incorrectly coding the fall history section of the resident’s annual Minimum Data Set (MDS) assessment. The resident, admitted with diagnoses including Alzheimer’s disease, heart failure, and dementia, experienced three unwitnessed falls in her room during the assessment look-back period, as documented in nurse’s progress notes and a fall event record. Each time, the resident was found sitting on the floor and assessed by nursing staff, with documentation indicating no injury from any of the falls. Despite this documented fall history, the annual MDS assessment indicated that the resident had no falls since the prior assessment. During interviews, the MDS Coordinator confirmed she was responsible for completing the fall history on the annual MDS and that she reviewed the resident’s fall event history when coding the assessment. She acknowledged that, based on the documented falls occurring after the prior MDS, the annual MDS should have been coded to reflect two or more falls without injury. The DON and the Administrator both stated that MDS assessments are expected to be accurate and correctly coded, and that the annual MDS should have reflected that the resident had fallen since the prior assessment.
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