Inaccurate Resident Assessment in MDS
Penalty
Summary
The facility failed to ensure that the resident assessment accurately reflected the resident's status for one of the residents reviewed. Specifically, the clinical record review and staff interview revealed that a resident, diagnosed with cerebral infarction and gastro-esophageal reflux disease, was inaccurately assessed in the Minimum Data Set (MDS) as having been treated for Post Traumatic Stress Disorder (PTSD) in the previous seven days. However, the resident's electronic medical record did not show any treatment for PTSD, nor was there a care plan addressing PTSD. The Director of Nursing confirmed that the MDS was marked in error and that the resident did not have a history of PTSD.
Plan Of Correction
Preparation and evaluation of the enclosed plan of correction set forth in these documents does not constitute admission or agreement by the provider of the truth of the facts alleged or concluded set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provision of Federal and State law. F-0641- Accuracy of Assessments 1. Resident #49 MDS was modified on 1/22/25 removing that the resident had been treated for PTSD in section I6100. DON did a written education for the LPNAC that entered this incorrectly. 2. All assessments completed in the past 14 days were audited for accuracy in section 16100 with no other errors identified. 3. Policies for Resident Assessments and comprehensive Assessments has been reviewed and will be revised as needed by the DON. Re-education provided to the MDS team by the DON on 1/31/2025 on accuracy of assessments per the RAI manual. Ongoing MDS training courses will be scheduled for the MDS team as offered and appropriate. 4. MDS's completed by the LPNAC will be audited by RNAC for accuracy. Audits will be completed on random sections of the MDS completed by the LPNAC. 5 assessments will be audited bi-weekly X2, then monthly x3 in coordination with residents MDS schedule. MDS will be modified if any errors identified. Any error identified will be brought to DON attention immediately. Audits will be reviewed at QA Meetings. All corrective actions will be completed by 2/25/25.