F0641

D

Inaccurate MDS Coding for Falls and Restraints

Fayetteville, North Carolina Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for falls and restraints for three residents. One resident with epilepsy experienced multiple documented falls over several days, including being found on the floor on his buttocks, lying on his side on a fall mat, sliding from a wheelchair to the ground, and being observed on the floor beside his wheelchair, all with no injury noted. Despite these documented events, his discharge MDS indicated no falls with no injury, one fall with injury, and no falls with major injury. The MDS Coordinator, who completed this assessment, acknowledged awareness of the resident’s multiple falls and confirmed that the discharge MDS was incorrectly coded for falls, though she was unsure how the error occurred. The Administrator stated she expected all MDS assessments to be accurate and timely.

Another resident admitted with cerebrovascular accident and muscle weakness had two documented falls on the same day, both witnessed and without injury, one from attempting to get out of bed and another from trying to get out of a chair. However, the admission MDS for this resident indicated there had been no falls since admission. The MDS Coordinator, who completed this assessment, confirmed the MDS was incorrectly coded for falls and could not explain how the error occurred. A third resident, admitted with cerebral infarction and vascular dementia and with no physician orders for physical restraints, was coded on a quarterly MDS as having a trunk restraint used less than daily. The MDS Coordinator stated that this resident did not have a restraint and that there were no restraints used in the facility, characterizing the restraint coding as an oversight. The Regional Nurse Consultant and the Administrator both stated their expectation that MDS assessments be coded correctly.