Inaccurate MDS Documentation for Residents
Penalty
Summary
During a Recertification Survey, the facility was found to have deficiencies in accurately reflecting residents' statuses in their assessments. Specifically, the Minimum Data Set (MDS) 3.0 assessment for two residents was inaccurate. One resident, who had a history of wandering behavior and was observed with a Wanderguard on multiple occasions, was documented in the MDS as not using a Wander/elopement alarm. This discrepancy was noted despite the resident's care plan and physician orders indicating the use of a Wanderguard. Another resident, who was admitted with a diagnosis affecting their ability to communicate, was inaccurately documented in the MDS as having clear speech and the ability to make themselves understood. Observations showed the resident using gestures to communicate due to slurred speech, and staff confirmed the resident's nonverbal status. The MDS Coordinator acknowledged the inaccuracies but could not explain the errors as the responsible MDS Assessor was on medical leave. The Director of Nursing stated that the Nursing Department collaborates with the MDS Department to ensure the accuracy of MDS documentation.
Plan Of Correction
Plan of Correction: Approved January 31, 2025 F 641 483.20 Accuracy of Assessment SS=D I. The following actions were accomplished for the resident(s) identified in the sample: The DNS reeducated the MDS Coordinator submitted a correction of the MDS for Resident #36 and #6 on 1/7/2025. The DNS reeducated the MDS Coordinator regarding responsibilities to ensure the accuracy of MDS data prior to submission. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have the potential to be affected by the same practice. The MDS Coordinator/Designee will review assessments, progress notes, and plan of care to ensure accuracy of MDS completion prior to submission. The MDS Coordinator will review the last submitted MDS assessment for all residents to ensure the assessment accurately reflects the resident's status at the time the assessment was completed. A correction MDS will be submitted as needed. III. The following system changes will be implemented to ensure continuing compliance with regulations: The MDS Coordinator/Designee will develop an audit tool to review all scheduled MDS for accuracy prior to submission. The audit tool will assess residents' plan of care, progress notes, and assessment to ensure accuracy and the same practice does not recur. The Administrator, DNS, and MDS Coordinator reviewed the policy and procedure entitled "Minimum Data Set Assessment Completion." No revision is needed at this time. The DNS/Designee will provide education to the MDS Coordinator regarding the above protocol emphasizing the importance of the MDS including accurate data assessment to ensure the CCP addresses each resident's strengths, care needs, including the use of wander alert devices and resident communication ability as applicable. All IDCPT members responsible for completing sections of the Residents Assessment Instrument (RAI) will be provided with this education and training. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The MDS Coordinator/Designee will monitor the same practice does not recur through weekly audits of scheduled MDS. The audit tool will be utilized to ensure the MDS is accurate prior to submission and monitor compliance with accuracy of MDS data. The audit will occur weekly for six months or until two quarters are at 100% compliance. The RN/MDS Coordinator will audit 15% of completed MDS assessments monthly for six months. All MDS accuracy audit findings will be reported to the Administrator and DNS on a monthly basis. Corrective actions, such as submitting a correction MDS, will be implemented as indicated. The MDS Coordinator will report MDS accuracy audit findings to the QAPI Committee for six months. Responsible: The MDS Coordinator/Designee is responsible to ensure regulation compliance.