Long-Term Care Survey Alert
Know What You Need to Count as a Fall on MDS
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A: If a resident would have fallen without your intervention, youd count that as a fall on the MDS assessment. This should be distinguished from steadying someone with a hand at the first sign of what you think might be a balance problem. Thats a judgment call that few can or should second guess. So relax and if you think the resident would have fallen, document it as such in the MDS and nurses notes. The intervention of lowering the resident to the floor without injury is a great outcome.
The consequence of not documenting the event is hard to gauge. In the simplest terms, it would be inaccurate not to document the incident as a fall. In and of itself it is a relatively limited finding for a surveyor in most circumstances. But it is an important observation for care planning.
Expert advice provided by former Ohio survey agency chief Kurt Haas, a consultant in Lithopolis, OH.
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