Inaccurate MDS Coding of Resident Fall History
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate MDS assessment of a resident’s fall history. A progress note dated 07/30/25 at 3:45 a.m. documented that Resident #36 reported rolling out of bed onto the floor, with complaints of left shoulder pain and right knee pain, and observation that the right knee appeared slightly larger than the left. A care plan initiated the same day documented that the resident had a fall on 07/30/25 and included interventions such as use of a fall mat next to the bed and education not to sleep on the edge of the bed. Despite this documented fall and related care plan, the resident’s annual MDS assessment dated 10/15/25 indicated that the resident had not had any falls since admission, entry, reentry, or the prior assessment. On 01/08/26, during review of the annual assessment, the MDS coordinator acknowledged that the annual assessment was not accurately coded regarding the resident’s fall history, demonstrating that the facility did not complete a comprehensive and accurate assessment as required by its MDS 3.0 Completion policy and federal regulations.
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