Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents, leading to discrepancies in their Minimum Data Set (MDS) documentation. For one resident, who had diagnoses of hypertension and anxiety, there was a physician's order for oxygen therapy to maintain saturation above 91% as needed for shortness of breath. Despite being administered oxygen on multiple occasions, the MDS did not reflect the use of oxygen therapy, marking it as 'No'. This discrepancy was identified during a review of the clinical records and confirmed through an interview with the Nursing Home Administrator. Another resident, diagnosed with major depressive disorder and dementia, had a physician's order for a bed alarm. However, the MDS inaccurately marked the use of a bed alarm as 'No'. This error was also identified during a clinical record review and confirmed in an interview with the Nursing Home Administrator. Both instances highlight the facility's failure to ensure that the MDS accurately reflected the residents' current status and care needs, as required by regulations.
Plan Of Correction
1. Residents 8 and 60 had modifications of their MDS completed. 2. An initial audit of MDS completed in the past 30 days was completed to ensure accuracy of Section 00110 C1 and P0200 A. 3. Education was completed with MDS staff on ensuring accuracy of these sections of the MDS. 4. 5 audits of Section 00110 C1 and 5 audits of Section P0200 A will be completed weekly x 4, then monthly x 2 by DON or designee. Results of these audits will be shared with the QAA committee for review. 5. The facility will be in substantial compliance by 1/7/25.