Inaccurate Resident Assessments in MDS
Penalty
Summary
The facility failed to ensure accurate assessments of residents' conditions, as evidenced by discrepancies in the Minimum Data Set (MDS) assessments for two residents. Resident 108, admitted with hemiparesis following a cerebral infarction, was incorrectly assessed as having no impairment in her upper extremities, despite her own report of limited range of motion on her right side. This error was confirmed by the Director of Nursing. Similarly, Resident 112's MDS inaccurately recorded his discharge status as being to a hospital, while nursing documentation indicated he was discharged to his home. This discrepancy was also confirmed by the Director of Nursing.
Plan Of Correction
1. MDS for Resident 108 has been modified to reflect impairment. Resident 112 MDS modified to reflect correct discharge placement. 2. DON / Designee will audit recent MDS completed in the past 30 days to identify other potential inaccuracies. 3. DON/Designee will educate RNACs on 483.20(g) Accuracy of Assessments. 4. DON/Designee will do a random audit weekly x4 and monthly x3 to accuracy of MDS assessments. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.