Inaccurate MDS Coding for Fall History and Urinary Catheter Use
Penalty
Summary
Facility staff failed to ensure accurate completion of MDS assessments for two residents, resulting in incorrect coding of key clinical information. For one resident admitted after a fall that caused a left intertrochanteric femur fracture, hospital records and a nurse practitioner’s initial note documented that the resident had fallen, resulting in hip pain, inability to ambulate, and the fracture. Despite this clear history, the admission MDS with an assessment reference date of 1/20/26 coded Section J1700A (fall history in the last month prior to admission/entry or reentry) as “9 – unable to determine,” rather than capturing the documented fall. For another resident with a physician’s order for a Foley catheter for urinary retention, surveyor observation from the hallway showed a Foley drainage bag with urine hanging at the bedside. The resident’s quarterly MDS with an assessment reference date of 1/6/26 coded Section H0300 (urinary continence) as “always incontinent.” Because the resident had an indwelling urinary catheter in place, urinary continence should have been coded based on catheter use rather than rated as incontinence. In both cases, the MDS Coordinator confirmed the coding errors during interview.
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