Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete MDS assessments for two residents, leading to discrepancies in their medical records. For one resident, the Quarterly MDS indicated the use of physical restraints daily, despite no physician orders or care plans supporting this, and no restraints were observed during a facility visit. A licensed nurse confirmed that the MDS assessment was coded in error. For another resident, the Discharge MDS inaccurately documented the discharge destination. The resident was discharged to a short-term general hospital, contrary to the discharge plan and progress notes indicating the resident's intention to go home with family. A licensed nurse acknowledged that the discharge MDS assessment was also coded in error.
Plan Of Correction
Resident R96 Quarterly MDS has been revised to remove use of physical restraints. Resident R187 Quarterly MDS has been revised to reflect discharge to home. MDS Coordinator / Designee to conduct an initial audit of residents in past 30 days with Quarterly MDSs for accuracy of physical restraints and discharge disposition. NPE / DON / Designee to re-educate MDS Coordinators regarding accuracy of Quarterly MDS submissions. MDS Coordinator / Designee to complete weekly audits X 4 then monthly X 2 for residents with Quarterly MDSs to ensure accuracy of submissions for physical restraints and discharge disposition. MDS Coordinator will report the findings of the audits to the QAPI Committee X 3 months.