Inaccurate MDS Assessment for Restraints
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) Assessments accurately reflected the status of a resident. Specifically, the quarterly review MDS for a resident, dated November 2, 2024, incorrectly indicated that the resident had a form of restraints in place. However, a review of the resident's clinical record did not reveal any evidence of restraints being used. The resident was admitted with diagnoses including cardiovascular disease, depression, and diabetes. An interview with the Director of Nursing confirmed that there were no physician's orders for restraints, nor did the resident require them, indicating that the MDS was coded in error.
Plan Of Correction
Resident MDS was corrected on 12/9/2024. To identify residents with the potential to be affected, MDS assessments in the last 14 days will be reviewed for accuracy by the MDS coordinator. To prevent this from recurring, education will be provided to the MDS coordinator by the regional MDS coordinator regarding MDS accuracy. To monitor and maintain compliance, 5 random charts will be reviewed weekly x 4 and then monthly x 2 for accuracy by the MDS coordinator/designee. All results will be brought to the QAPI committee.