Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in their documented clinical status. Resident 179, who was admitted with chronic obstructive pulmonary disease and dementia, had a quarterly MDS assessment that inaccurately indicated no wandering behaviors, despite clinical records documenting multiple incidents of wandering into other residents' rooms. This discrepancy was confirmed by the Nursing Home Administrator. Resident 159, admitted with psychosis, had inaccuracies in their MDS assessment regarding medication management. The assessment incorrectly indicated the use of a hypnotic medication and failed to document a Gradual Dose Reduction (GDR) attempt for antipsychotic medication. Clinical records showed a physician's order to discontinue and later reinstate the antipsychotic medication Secuado, following a failed GDR attempt. The Director of Nursing confirmed the inaccuracies in Resident 159's MDS assessment.
Plan Of Correction
Step 1- R 159 and R179's MDS's were corrected and submitted. Step 2- To identify other residents that have the potential to be affected, the regional MDS staff will audit MDS assessments completed in the last 7 days will be reviewed for accuracy- areas of concern will be corrected and resubmitted. Step 3- To prevent this from reoccurring, education will be completed with the members of the IDT by the regional MDS re: ensuring all MDS assessments are completed accurately. Step 4- To monitor and maintain compliance, 10 residents Quarterly, Admission, or Significant Change MDS assessments will be completed by the MDS nurse/designee for accuracy. The audits will be completed weekly times 4 weeks and then monthly times 4. The results of the audits will be forwarded to QAPI committee for further review and recommendations.