Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for three residents, leading to deficiencies in reflecting their current medical status. For one resident, the Medication Administration Record indicated an ongoing order for Olanzapine, an antipsychotic medication, since September 2024. However, the Minimum Data Set (MDS) assessment completed in December 2024 did not reflect the administration of antipsychotic medications, despite the resident receiving them. The Nursing Home Administrator later acknowledged the incorrect coding of the MDS assessment. Another resident had an active colostomy, as noted in a physician encounter report, and required colostomy care every shift. Despite this, the September 2024 MDS assessment did not indicate the presence of an ostomy. Similarly, a third resident was receiving wound care for a diabetic ulcer on the left heel, as documented in a wound consult report. However, the December 2024 MDS assessment failed to reflect the presence of a diabetic ulcer. The Nursing Home Administrator confirmed the existence of these MDS errors.
Plan Of Correction
1. Resident 1, 13, 64 had MDS modified during survey to correct data. The RNAC will be educated on the importance of reviewing the resident record and accurately documenting this information on the MDS. 2. Audit will be completed on residents with orders for Antipsychotics, Ostomies, and Pressure ulcers to ensure that resident medication/condition is accurately coded on the MDS. 3. DON or designee Audits for accurate MDS coding for Residents with Antipsychotics, ostomies, and pressure ulcers will continue for 5 Resident MDS weekly for 4 weeks, monthly for 2 months. 4. Audits and findings will be submitted in the Quarterly QAPI committee meetings.