Inaccurate MDS Assessment for Resident with Urinary Catheter
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the health and functional status of a resident, specifically regarding the diagnosis of an indwelling urinary catheter. During an observation and interview, it was noted that the resident had an indwelling urinary catheter, which was not coded in the MDS assessment. The resident was admitted with diagnoses including anxiety, kidney failure, and neuromuscular dysfunction, and had a moderate cognitive deficit. Despite the presence of the catheter, there was no corresponding order, diagnosis, or care plan documented in the resident's records. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), the Minimum Data Set Nurse (MDSN), and the Medical Records Director (MRD), revealed that the resident was admitted with the catheter, but the necessary documentation was missing. The LVN confirmed the absence of an order and diagnosis for the catheter, while the MDSN acknowledged that the catheter use was coded but not the diagnosis. The MRD, who was also a licensed nurse, was unaware of the catheter until reviewing the records and confirmed that the required documentation was only initiated days after the resident's admission. The Director of Nursing (DON) stated that the catheter was re-inserted after an unsuccessful attempt to discontinue it, due to the resident not voiding for eight hours. The DON admitted that the licensed nurse should have entered the order and obtained a diagnosis from the physician. The facility's policy on urinary catheters emphasized the need for valid medical justification and timely discontinuation, which was not adhered to in this case.
Penalty
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Below are regulatory guidelines relevant to this citation:
A resident with severe cognitive impairment and multiple diagnoses was documented in medical and dental assessments as having natural teeth with missing teeth and no dentures, while staff interviews revealed the resident actually had partial dentures. This inconsistency between staff knowledge and assessment documentation resulted in a deficiency related to inaccurate resident assessments.
A resident with diabetes and anxiety was documented in MDS assessments as having no dental issues, but was observed to be without natural upper teeth and reported losing teeth since admission without being offered dental assistance. Interviews with the MDS RN, an LPN, and the DON confirmed the inaccuracy of the resident's dental status in the MDS.
A resident was admitted with complex medical conditions and hospital records indicating buttock wounds, but the facility's admission assessment did not document these wounds. The MDS nurse, relying solely on hospital documentation and without conducting a personal assessment, recorded pressure injuries that were not present according to the facility's clinical evaluation. The discrepancy between hospital and facility findings was not addressed before completing the MDS assessment.
The facility did not accurately complete MDS 3.0 assessments for two residents, resulting in incorrect documentation of discharge status and failure to record multiple vascular wounds and pressure ulcers. These deficiencies were confirmed through medical record review and staff interviews.
A resident with dementia and a history of wandering and aggressive behaviors was admitted to the secure/memory care unit without an assessment to determine appropriateness for placement. The DON confirmed that the required assessment was not completed prior to admission, and only after placement was the resident's severe mentation impairment and exit-seeking behavior documented. This deficiency was identified during a complaint investigation.
A resident with dementia and behavioral disorders was discharged after the closure of a secured unit, with the process planned and coordinated with the family. However, the MDS assessment was inaccurately coded as an unplanned discharge due to a delay in the moving date, despite CMS guidelines indicating the discharge was planned.
Failure to Complete Accurate Dental Assessments
Penalty
Summary
The facility failed to ensure accurate assessments were completed for a resident with multiple diagnoses, including psychotic disorder with delusions, Parkinson's disease, anxiety, depression, dementia, and neurocognitive disorder with Lewy bodies. Medical record review showed that nursing admission and dental assessments consistently documented the resident as having natural teeth with missing teeth and no dentures. However, during staff interviews, a CNA reported that the resident had partial dentures, which was confirmed by the unit manager upon review of the assessments. The Minimum Data Set (MDS) assessment also indicated the resident had no broken or loosely fitting dentures and no mouth or facial pain, discomfort, or difficulty chewing. This discrepancy between staff knowledge and documented assessments led to the deficiency.
Inaccurate MDS Assessment of Oral/Dental Status
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for one resident out of four reviewed. A resident admitted with diagnoses including type II diabetes mellitus with polyneuropathy and generalized anxiety was documented in quarterly MDS assessments as having no oral or dental issues. However, observation revealed the resident was without natural upper teeth, and the resident reported losing several teeth since admission and not being offered assistance to see a dentist. Interviews with the MDS RN and an LPN confirmed uncertainty and inaccuracy regarding the resident's dental status, and the Director of Nursing acknowledged the MDS assessment did not accurately reflect the resident's oral or dental condition.
Inaccurate Admission MDS Skin Assessment Due to Unresolved Documentation Discrepancy
Penalty
Summary
The facility failed to ensure the accuracy of an admission Minimum Data Set (MDS) skin condition assessment for one resident. Upon review, the resident was admitted with diagnoses including surgical aftercare, colostomy status, pulmonary embolism, and malignant neoplasm of the colon. Hospital discharge documentation indicated the presence of a right buttock wound and a left buttock deep tissue injury. However, the facility's admission wound assessment, completed by the Director of Nursing (DON), documented only a surgical incision to the abdomen and a stage two pressure ulcer of the left axilla, with no mention of wounds to the buttocks. The admission MDS assessment, completed by an MDS Registered Nurse who had not personally assessed the resident, recorded a stage two pressure ulcer and a deep tissue injury based solely on hospital documentation. During interviews, the MDS nurse admitted uncertainty about how to proceed when hospital records and clinical assessments did not align, as she was still in training. Subsequent observation and interviews confirmed the absence of pressure ulcers or deep tissue injuries on the buttocks at admission. The facility's policy required interdisciplinary participation in resident assessments, but the discrepancy between hospital and facility findings was not resolved prior to completing the MDS assessment.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) 3.0 assessments were completed accurately for two residents. For one resident, the MDS assessment indicated 'discharge return anticipated' after a hospital transfer, but the resident did not return to the facility. This error was confirmed by the MDS nurse during an interview. For the second resident, the initial nursing evaluation upon readmission did not address multiple vascular wounds to the left foot, and the five-day MDS assessment failed to document these wounds. Additionally, the resident's skin and wound evaluation noted an unstageable pressure ulcer on the right heel, but the assessment lacked wound measurements. Further review of the five-day MDS assessment for the second resident showed inconsistencies regarding cognitive status and assistance needs, and it did not address vascular wounds to the right toes. The MDS coordinator confirmed that the assessments did not reflect all existing wounds. These deficiencies were identified through medical record review and staff interviews during a complaint investigation.
Failure to Complete Assessment Prior to Secure Unit Placement
Penalty
Summary
The facility failed to complete an assessment prior to placing a resident on the secure/memory care unit. Record review showed that the resident was admitted with multiple diagnoses, including ataxia, dementia, psoriatic arthropathy, recurrent depressive disorder, wandering, and adult failure to thrive. The care plan identified the resident as an elopement risk due to behaviors such as pacing the halls and wandering into other resident rooms, and included interventions like checking the secure tech bracelet and encouraging family involvement. However, there was no evidence in the medical record that an assessment was conducted to determine the appropriateness of placement on the secure unit before admission. Interview with the DON confirmed that the assessment was not completed prior to the resident's admission to the secure unit. A functional assessment was only completed after the resident was already on the unit, which documented severe mentation impairment, uncooperative and resistive behaviors, wandering, verbal and physical abuse, social inappropriateness, and exit-seeking. The resident had a history of attempts to exit home, aggression, and had recently attempted to exit the building, triggering the alarm. This deficiency was identified during a complaint investigation.
Inaccurate MDS Assessment Coding for Discharge
Penalty
Summary
The facility failed to complete an accurate comprehensive assessment for a resident with Alzheimer's disease, schizoaffective disorder, and intermittent explosive disorder. The resident was admitted with a high risk for elopement, aggression, and required close supervision in a secured unit. Due to the closure of the secured unit, the resident and family were given a 30-day notice for discharge, as the resident's needs could not be met on the main floor. The discharge was scheduled and anticipated, with the family involved in planning and arranging for the resident's personal items to be moved. Despite the planned nature of the discharge, the Minimum Data Set (MDS) assessment was coded as an unplanned discharge by the RN, based on the discharge occurring a day later than originally scheduled. Interviews with staff confirmed that the delay was due to logistical reasons related to moving the resident's belongings, not due to an acute medical event or an unexpected decision by the resident. The Centers for Medicare and Medicaid Services (CMS) guidelines define an unplanned discharge as one resulting from an acute medical need or an unexpected departure, which did not apply in this case. This misclassification resulted in an inaccurate assessment for the resident.
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