Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two residents. Resident 102 was admitted with pneumonia, which was resolved by October 10, 2024. However, the MDS assessment dated November 15, 2024, incorrectly indicated that the resident still had pneumonia, despite no evidence in the clinical record supporting this. The error was confirmed by the Administrator. Resident 108's MDS assessment inaccurately documented a discharge to a hospital setting, while physician progress notes indicated the resident was discharged home. This discrepancy was confirmed by the Nursing Home Administrator. These inaccuracies in MDS assessments were previously cited on December 1, 2023, under the regulation S483.20(g) for the accuracy of assessments.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. F0641 1. MDS corrections were submitted for residents 102 and 108. 2. Current residents with MDS completed from January 6, 2025, through January 20, 2025, will be reviewed to determine accuracy of section I 2000. Current residents with MDS completed from January 6, 2025, through January 20, 2025, will be reviewed to determine accuracy of section A2105. 3. Education will be completed with Social Services on accuracy of section A 2105 of the MDS. Education will be provided to the RNAC on accuracy of section I 2000 of the MDS. 4. Random audits will be completed by DON or designee weekly for 4 weeks, then monthly for 2 months of residents' MDS to ensure accuracy of sections A 2105 and I 2000. Results of audits will be presented at the Quality Assurance Performance Improvement Committee meeting for review and recommendations.