Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) Assessments accurately reflected the status of three residents. For one resident, the MDS assessment inaccurately reported no significant weight loss, despite a documented 10.04% weight loss over six months. This discrepancy was confirmed by the Registered Dietitian during an interview. Another resident's MDS assessment incorrectly coded the type of entry as an admission instead of a reentry after a hospital transfer, as confirmed by the Registered Nurse Assessment Coordinator (RNAC). Additionally, a third resident's MDS assessment inaccurately indicated that the resident received insulin injections, despite no documented evidence or physician order for such treatment. This error was also confirmed by the RNAC. These inaccuracies in the MDS assessments highlight a failure in accurately documenting and reflecting the residents' medical statuses, as required by the Resident Assessment Instrument (RAI) guidelines.
Plan Of Correction
1. Resident 34 still resides at facility and her MDS has been modified. Resident 8 still resides at facility and her MDS has been modified to reflect her admission date. Resident 31 no longer resides at facility. His MDS has been modified. 2. The facility will complete an audit of the most recently completed MDS for each current resident, to ensure Sections K0300, A1700, and N0350 are coded correctly. 3. The DON/designee will provide education to the RNAC on MDS accuracy of Sections K0300, A1700, and N0350. 4. The Consultant RNAC/designee will perform weekly audits of sampled MDS Sections K0300, A1700, and N0350 to ensure they are coded correctly. Results will be reviewed at the facility's monthly QAPI meeting. Audits will continue until substantial compliance is reached.