Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set 3.0 (MDS) assessments accurately reflected the status of two residents. For one resident with diagnoses including unspecified dementia, anxiety disorder, and depression, the MDS assessment inaccurately documented that it was not very important for the resident to keep up with the news and do their favorite activities. This was contrary to an Activities Evaluation which indicated these activities were very important to the resident. The Activities Director admitted to an error in coding due to being busy, which led to the inaccurate documentation in the MDS assessment. For another resident with diagnoses including unspecified dementia, muscle weakness, and difficulty in walking, the MDS assessment failed to document the use of a wander guard, which was ordered by a physician and used for safety due to the resident's wandering behavior. The MDS Assessor did not recall the presence of the wander guard during the assessment and acknowledged the error after reviewing the medical record. The MDS Coordinator stated that their role was to ensure timely completion and submission of MDS assessments, not to review their accuracy.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 Element 1 F641: The MDS assessments for resident #237 were modified, and television was immediately provided to the resident. Resident #237 was re-interviewed, and the activity preference was updated to reflect the current choices. The Care Plan was updated and implemented. Activity staff will continue to monitor for changes in preference. On 12/19/2024, the MDS for resident #436 had not been locked for submission; therefore, no MDS modification was required. The MDS was reviewed and locked on 12/19/2024 and cued for submission, which was still within the allowable time frame. MDS Nurse was re-in-serviced to properly assess and review records to accurately reflect resident needs in MDS. Element 2 Residents at Risk: This practice could affect all residents. A full audit was conducted on all active MDS assessments within the last 90 days to identify any additional inaccuracies. No other issues were identified. Element 3 Systemic changes: The Policy and Procedures for MDS Guideline for Completion were reviewed, and no revisions were required. All RN Assessors were re-in-serviced on the Policy and Procedure MDS Guidelines for Completion, emphasizing that MDS accurately reflects the residents' current status with emphasis on Section P. Activities director/designees will cross-check Section F for MDS accuracy. Training includes proper data collection, resident interviews, and validation of information before transmission. The Activity Director will audit for accuracy every week to ensure the accuracy and consistency of the resident's preferences. Staff will complete the activity form on all comprehensive assessments, initiate and implement the care plan, and complete MDS. Activity will complete activity preference form on all comprehensive assessments and as needed if residents' preferences change. An audit tool was developed to monitor compliance. Element 4 Monitoring of Corrective Action: To ensure ongoing accuracy, the MDS Coordinator/RN assessors and Activities Director will conduct random audits of 10% of completed MDS assessments weekly for 3 months. The audit results will be reported to the Administrator and Director of Nursing for compliance. Audit results will be reviewed in quarterly QAPI meetings for one quarter. If any trends of inaccuracy are noted, additional interventions will be implemented. QAPI Committee will determine if any further action is required. Element 5 Completion Date: February 12, 2025 Responsible Persons: MDS Coordinator, RN Assessors, Activities Director.