Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Resident Assessments accurately reflected the residents' status for four out of seven residents reviewed during the recertification survey. Specifically, inaccuracies were found in Section I - Active Diagnoses and Section N - Medications. For one resident, the MDS inaccurately coded a psychotic disorder without documented evidence of psychosis-related behaviors during the look-back period. Another resident was incorrectly coded as receiving anticoagulant medications when only aspirin, an antiplatelet, was administered. Additionally, a resident was marked as receiving both antidepressant and antianxiety medications, although only an antidepressant was ordered and administered. Interviews with the MDS Coordinators revealed discrepancies in how they gathered and verified information for the MDS assessments. One coordinator relied on electronic records and internet searches to classify medications, leading to misclassification. The Director of Nursing was not informed of these issues, and the Administrator was unaware of any inaccuracies in the MDS assessments. The facility's policy required that the MDS accurately reflect the resident's status, but this was not adhered to, resulting in the identified deficiencies.
Plan Of Correction
Plan of Correction: Approved February 7, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. The MDS assessments for the 4 affected residents will be corrected and resubmitted. 2. All resident MDS assessments have the potential to be affected. The facility will audit all MDS assessments that were submitted last quarter to identify any other incorrect MDS coding. The nurses working in the MDS department will be educated on the requirement to ensure that all MDS assessments are accurately coded including [DIAGNOSES REDACTED]. 3. The medications are to be coded according to the medication's therapeutic category and/or pharmacological classification, not on how they are used. An audit tool will be utilized to audit the medication and [DIAGNOSES REDACTED]. 4. The Accurate Assessment Audit will be conducted weekly x 4 and then monthly x 3 on three randomly selected completed MDS. The auditor will review the medication and [DIAGNOSES REDACTED]. Resident Assessment Instrument 3.0 User's Manual, dated (MONTH) 2024. Results of the audits will be brought to the QAPI meeting for review. The Director of Nursing is the responsible party.