Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for seven residents, as determined through a review of clinical records and staff interviews. The inaccuracies were found in various sections of the MDS assessments, which are crucial for reflecting the residents' medical and treatment statuses. For instance, Resident 12's assessment inaccurately indicated that the influenza vaccine was not offered, despite documentation showing the resident refused it. Similarly, Resident 17's assessment failed to record the administration of gabapentin, an anticonvulsant medication, which was given as per the physician's orders. Further discrepancies were noted in the assessments of other residents. Resident 18's MDS assessment did not reflect the administration of bumetanide, a diuretic medication, despite records showing it was administered daily. Resident 25, who required hemodialysis, had an assessment that did not indicate the receipt of dialysis treatments, contrary to nursing notes. Additionally, Resident 41's assessment failed to record the administration of diazepam, an anti-anxiety medication, which was given daily as ordered. The inaccuracies extended to Resident 93, whose assessment incorrectly stated that vaccines were not offered, despite declination forms indicating refusal. Resident 122's assessment did not reflect the administration of Tramadol and Topiramate, despite records showing these medications were given. Interviews with the Licensed Practical Nurse Assessment Coordinator confirmed these coding errors, highlighting a failure in accurately documenting the residents' treatment and medication administration in the MDS assessments.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This Plan of Correction (POC) does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #12 will have a corrected Minimum Data Set (MDS). Resident #17 will have a corrected MDS. Resident #18 will have a corrected MDS. Resident #25 will have a corrected MDS. Resident #41 will have a corrected MDS. Resident #93 will have a corrected MDS. Resident #122 will have a corrected MDS. To identify other residents with the potential to be affected, the MDS nurse/designee will audit the most recent MDS assessment of residents to ensure they are coded correctly. Modifications will be made as necessary. To prevent a future occurrence, the Nursing Home administrator/designee provided education to the MDS nurses on proper coding of the MDS items. To monitor and maintain ongoing compliance, the MDS team/designee will complete an audit weekly x4 then monthly x2 to ensure MDS assessments are being properly coded. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.