F0641

D

Inaccurate MDS Coding for Falls and Bed Rail Use

Riverdale, Georgia Survey Completed on 03-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure accurate completion of MDS assessments for two residents. For one resident with diagnoses including bradycardia, epilepsy, and vascular dementia, the quarterly MDS dated 01/19/2026 documented no falls in Section J, despite facility incident records showing the resident sustained a substantiated unwitnessed fall on 12/06/2025, during which the resident was unresponsive, did not respond to commands, and was transported to the hospital via 911. The resident later stated he had fallen in the past and gone to the hospital once, and an LPN reported the resident had two unwitnessed falls and was sent to the hospital in December 2025 for a fall with possible seizure activity. The MDS Coordinator confirmed that the fall on 12/06/2025 should have been coded on the 01/19/2026 quarterly MDS and that Section J was not accurately completed.

For another resident admitted and readmitted with diagnoses including peripheral vascular disease, the quarterly MDS dated 12/18/2025 documented a BIMS score of 15 in Section C and indicated daily use of bed rails in Section P. However, the resident’s care plan dated 12/21/2025 contained no focus area for restraint use, and the physician’s orders contained no order for restraints. Multiple observations over several days showed the resident in bed or in the room without any bed rails on the bed. The resident stated he did not have bed rails and could transfer without them. The MDS Coordinator confirmed that the MDS incorrectly documented bed rail use, and the Unit Manager stated the resident did not use bed rails, there were no physician’s orders for bed rails, and an audit of bed rail use had been provided to the MDS Coordinator for updating MDS assessments.