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 medical status. For one resident, the MDS assessment inaccurately indicated that the resident had not received several medications, including an anti-anxiety medication, an antidepressant, an anticoagulant, and an antibiotic, despite physician's orders confirming their administration. This discrepancy was confirmed during an interview with the Nursing Home Administrator, who acknowledged the incorrect coding of the resident's MDS assessment. Another resident's MDS assessment was also inaccurately coded regarding their discharge status. The assessment indicated that the resident was discharged to the hospital, while nursing notes documented that the resident was discharged home with his brother. This error was similarly confirmed by the Nursing Home Administrator during an interview, highlighting a failure in accurately reflecting the resident's discharge status in the MDS assessment.
Plan Of Correction
1. Resident 63 significant change assessment, assessment reference date of 11/29/2024 was corrected and resubmitted to include the following medications: N0415B, N0415C, N0415E and N0415F. Resident 78 discharge assessment was corrected and resubmitted on 2/4/2025. 2. Any resident has potential to be affected by this deficient practice. 3. Staff have been reeducated on section N for medication listing and section A for discharge disposition. 4. Six random assessments a week will be audited times 4 weeks. These audits will verify that medications are properly coded and/or discharge disposition was correct. Audits will be submitted to Quality Assessment Team for review and to determine if audits should continue. Director of Nursing or designee will monitor.