Inaccurate MDS Assessment Related to Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate Minimum Data Set (MDS) assessment for a resident reviewed for falls. The resident was admitted with diagnoses including muscle weakness and an unspecified fall. Progress notes show that the resident experienced a fall and was transferred to the hospital for evaluation on 10/13/25. However, the admission MDS dated 10/14/25 documented that the resident had no falls since admission, omitting the fall that occurred on 10/13/25. In an interview, the MDS Coordinator confirmed that the resident had fallen on 10/13/25 and that this fall should have been documented on the admission MDS but was not. This failure to document the fall accurately on the federally mandated MDS assessment resulted in the resident’s assessment not reflecting the actual occurrence of a fall since admission.
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