Inaccurate MDS Coding of Resident Fall Event
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate Minimum Data Set (MDS) assessment related to a resident’s health conditions, specifically falls. The resident was admitted with diagnoses including traumatic subdural hemorrhage, repeated falls, restlessness, and agitation. An H&P dated 1/10/2026 documented that the resident had the mental capacity to understand but could not make medical decisions. An MDS dated 1/14/2026 indicated severe cognitive impairment, no acute change in mental status, no hallucinations or delusions, and that the resident required maximal assistance for bed mobility, transfers, and walking ten feet in the room. This MDS also indicated the resident had not experienced any falls since admission, reentry, or the prior assessment. On 1/16/2026, a Change of Condition (COC) documented that at 8:30 a.m. the resident got out of bed without using the call light to go to the bathroom, their knees buckled, and they made contact with the floor, sustaining a small bump and superficial cut to the nose with minimal bleeding. A subsequent MDS again documented that the resident had not had any falls since admission, entry, reentry, or the prior assessment, despite the documented fall on 1/16/2026. During interviews, the MDS Coordinator acknowledged that the 1/16/2026 event met the facility’s definition of a fall (any unintentional contact with the ground), that it was unwitnessed, and that it should have been coded as a fall on the MDS and as a fall since the prior assessment, but was not. The MDS Coordinator also confirmed that no significant error assessment was completed to correct the inaccuracy. The DON stated that facility policy requires assessments and documentation to be accurate, complete, and to include events, incidents, and accidents, and that this policy was not followed when the MDS failed to reflect the resident’s fall.
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