cms_MS: 11
Data source: Big Local News · About: big-local-datasette
rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
11 | JEFFERSON DAVIS COMMUNITY HOSPITAL ECF | 255050 | 1320 WINFIELD STREET | PRENTISS | MS | 39474 | 2018-10-31 | 641 | D | 0 | 1 | 63N611 | Based on record review, facility policy review, and staff interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for falls for one (1) of 12 Resident MDS assessments reviewed, Resident #25 Findings Include: Review of the policy documentation on facility letterhead, provided by the facility, dated 10/31/2018, no signature, revealed the facility followed the Resident Assessment Instrument (RAI) for Minimum Data Set (MDS) coding. Review of Resident #25's Quarterly MDS with an Assessment Reference Date (ARD) of 09/27/2018, revealed Section J1800 coded that no falls, with or without injury, had occurred. Resident #25 had a prior MDS assessment, with an ARD of 07/03/2018, where no falls were coded. Review of a Resident Incident Report, dated 08/17/2018, signed by the Administrator, revealed Resident #25 had a fall with head injury on 08/16/2018. Review of Departmental Notes, dated 08/16/2018 at 1:14 PM, revealed that Resident #25 fell when attempting to go to the bathroom unassisted. During an interview with the Director of Nursing (DON), on 10/30/2018 at 02:15 PM, the DON confirmed that Resident #25 had a fall with head injury on 08/16/2018. An interview with Licensed Practical Nurse (LPN) #1/MDS Coordinator, on 10/31/2018 at 10:40 AM, confirmed that Resident #25's MDS Assessment on 09/27/2018 had been miscoded relating to Resident #25's fall on 08/16/2018. LPN #1 stated that there was nursing documentation on Resident #25's fall with a major injury after the 07/27/2018 MDS assessment and before the 09/27/2018 MDS assessment. LPN #1 stated she agreed that Section J1800 of the 09/27/2018 MDS assessment should have been coded Yes indicating Resident #25 indeed had a fall on 08/16/2018. During an interview on 10/31/2018 at 11:08 AM, the Director of Nursing (DON) confirmed that Resident #25's 09/27/2018 MDS assessment had been miscoded, because of Resident #25's fall on 08/16/2018. | 2020-09-01 |