Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate resident assessments for three residents, leading to deficiencies in the documentation of their care needs. For Resident R1, the admission Minimum Data Set (MDS) indicated a serious mental illness and/or intellectual disability as determined by the Level II Preadmission Screening and Resident Review (PASRR). However, the annual comprehensive MDS inaccurately recorded that the resident was not considered to have such conditions, which was confirmed as an error by the Registered Nurse Assessment Coordinator (RNAC). This discrepancy highlights a failure in maintaining consistent and accurate assessments for residents with mental health conditions. Resident R17's MDS failed to document the ongoing use of oxygen therapy and BiPAP, despite active physician orders indicating the necessity of these treatments for conditions such as Chronic Obstructive Pulmonary Disease and Obstructive Sleep Apnea. Similarly, Resident R91's discharge status was inaccurately recorded as being discharged to a Short-Term General Hospital, while progress notes confirmed the resident was discharged home with family. These inaccuracies were confirmed by facility staff, including the Director of Nursing, indicating a systemic issue in the accuracy of resident assessments and documentation.
Plan Of Correction
RNAC made immediate modifications to the prior MDS assessments to correct for discrepancies for R1, R17, and R91. An immediate whole house audit was conducted to ensure MDS are accurate. Education was provided to the RNAC and RN supervisors by the DON or designee on the importance of correctly entering the diagnosis on the resident's chart upon admission. Audits will be completed by the DON or designee on accuracy of diagnosis and place of discharge during AM clinical weekly x four weeks and monthly x 1 month of all new admissions to compare the diagnosis from the medical records received upon admission to those entered in the EMAR to ensure accuracy. Audit results will be reviewed through the monthly QAPI process/meeting.