Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for four residents, leading to discrepancies in the documentation of their medical conditions and treatments. For one resident, the MDS assessment incorrectly indicated that the resident received injections during the assessment period, despite no documented evidence of such injections. Additionally, the assessment failed to note the presence of a nephrostomy tube, which was consistently treated as per physician's orders. Another resident's MDS assessment did not reflect the administration of insulin injections, which were documented in the Medication Administration Records (MARs), and incorrectly indicated the receipt of antibiotics, which were not administered. Further inaccuracies were found in the MDS assessments of two other residents. One resident's assessment failed to document the application of an antibiotic ointment to a diabetic ulcer, despite treatment records confirming its use. Another resident's assessment inaccurately coded the receipt of antipsychotic medication, despite consistent administration as per physician's orders. These errors were confirmed through interviews with facility staff, including the Assistant Director of Nursing and the Registered Nurse Assessment Coordinator, highlighting a failure in accurately coding and documenting resident assessments.
Plan Of Correction
1. Resident 35, 36, 48 and 60's current Minimum Data Set (MDS) assessments are accurate. Facility was unable to correct past MDS due to them being closed. 2. Review of residents with nephrostomy tubes, antibiotic ointment, insulin injections and antipsychotic medications were reviewed for accuracy. Registered Nurse Assessment Coordinator was educated on ensuring accuracy of the MDS coding with current orders. 3. Registered Nurse Assessment Coordinator or designee will audit three residents with nephrostomy tube, antibiotic ointment, insulin injections or antipsychotic medications weekly times four weeks and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.