Inaccurate MDS Coding of Physical Restraints for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected residents’ actual status, resulting in incorrect documentation of physical restraints for two residents. One resident with epilepsy and dementia, observed in a wheelchair on 4/12/26 with no restraints in the wheelchair or bed, had a quarterly MDS that coded in section P0100 “Physical Restraints, Other used daily” for restraint use. Another resident with diabetes and an above-the-knee left leg amputation, observed in bed with a trapeze bar used to assist with repositioning and with no restraints in the bed or wheelchair, had an admission MDS that also coded in section P0100 “Physical Restraints, Other used daily” for restraint use. On 4/13/26, the DON and MDS coordinator stated that these MDS assessments were coded incorrectly and confirmed that neither resident had restraints, indicating that the inaccurate coding stemmed from staff error in completing the MDS.
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