Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to maintain accurate assessments for two residents, leading to deficiencies in their clinical records. For Resident 97, the Quarterly Minimum Data Set (MDS) inaccurately indicated that the resident had experienced two falls with major injury since admission or the prior assessment. However, a review of the clinical record revealed no evidence of such falls. This discrepancy was confirmed by the Director of Nursing, who acknowledged the inaccurate coding of the MDS. Similarly, Resident 108's Quarterly MDS inaccurately reported both significant weight loss and gain. Upon reviewing the clinical record and weight summaries, no evidence of significant weight loss was found. The Director of Nursing confirmed the inaccuracy in the MDS coding for Resident 108 as well. These inaccuracies in the MDS assessments were identified as deficiencies under the relevant Pennsylvania Code sections for clinical records and nursing services.
Plan Of Correction
1. R97 had no evidence of falls with major injury - her MDS was corrected during the survey. R108's MDS has been corrected. 2. November's QM Report was reviewed for residents who had been coded as having had weight loss and falls with major injury. 3. The RNAC and Nutritional Service teams have been re-educated on accurate MDS. 4. Weekly audits will be conducted by the RNAC manager and Nutritional Service manager / designee to confirm accurate MDS in weight loss and falls with major injury for (4) weeks. These audits will be reviewed, trended, and determined for the need for future audits deemed by the QAPI team.