Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the documentation of their care needs. For Resident 61, the MDS assessment inaccurately indicated that the resident did not receive an injection during the seven-day assessment period, despite physician's orders and Medication Administration Records (MARs) confirming that 0.1 mL of Tubersol Solution was administered intradermally on December 3, 2024. This discrepancy was confirmed during an interview with the Director of Nursing. Similarly, the MDS assessment for Resident 74 inaccurately recorded that the resident did not receive antianxiety medication during the seven-day look-back period. However, physician's orders and MARs showed that the resident was prescribed and received 10 mg of Buspirone twice daily during this period. This error was also confirmed by the Director of Nursing. These inaccuracies in the MDS assessments indicate a failure to properly document the residents' medication administration, as required by the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual.
Plan Of Correction
1. The Minimum Data Set, MDS, for R61 and R74 have been corrected and re-submitted to Internet Quality Improvement & Evaluation System (IQUIES). 2. The Director of Nursing or designee will audit the last Minimum Data Set, MDS, for each resident to determine accuracy of assessment in section J, section O and section N. All issues identified will be corrected per the Resident Assessment Instrument, RAI, manual and resubmitted if warranted. 3. The Director of Nursing or designee will re-educate interdisciplinary team on the Resident Assessment Instrument Manual, RAI, guidance for MDS accuracy and coding criteria. 4. The Director of Nursing or designee will audit 5% of all newly completed MDS's for accuracy in section J, section O and section N. The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.