F0641

E

Inaccurate MDS Coding of Bedrails as Physical Restraints

Phillipsburg, Kansas Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

Surveyors found that the facility failed to ensure accurate completion of MDS assessments for five residents regarding the use of bedrails as restraints. For these residents, multiple Quarterly MDS assessments documented that bedrails were used as physical restraints on a daily basis during the look-back periods. Specifically, the MDS assessments dated 01/20/25, 11/25/25, 01/16/26, 02/15/26, and 12/20/25 each indicated daily use of bedrails as physical restraints. However, during an interview on 03/10/26 at 4:06 PM, Administrative Nurse D stated she had coded bedrails as restraints on the MDS for all residents whose beds had bedrails installed, regardless of whether the residents actually used the bedrails or whether the bedrails restricted their mobility.

Administrative Nurse D further confirmed that, for the identified residents, the bedrails did not restrict mobility and therefore did not meet the definition of a restraint, despite being coded as such on the MDS. She also stated that her expectation was that MDS assessments accurately reflect each resident’s status. The facility’s undated “Minimum Data Set (MDS) Accuracy Audits” policy documented that the facility was committed to ensuring the accuracy, timeliness, and completeness of all MDS assessments, which contrasted with the inaccurate coding practice described.