Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for four residents, leading to discrepancies in the documentation of their medical conditions. For one resident with an ostomy, the MDS inaccurately indicated bowel continence, despite physician orders confirming the presence of an ostomy. Another resident's MDS failed to reflect a Stage 4 pressure ulcer, as documented in a skin and wound note, leading to an inaccurate assessment of the resident's skin condition. Additionally, the MDS for a resident receiving Trazadone, an antidepressant, did not record the medication during the assessment period, despite physician orders and the Medication Administration Record confirming its administration. Furthermore, a resident receiving Seroquel for dementia with agitation had an MDS that inaccurately indicated no physician-documented Gradual Dose Reduction (GDR) as clinically contraindicated, despite a pharmacy recommendation and physician's decision against a GDR.
Plan Of Correction
Plan of Correction: 1. The Minimum Data Set assessments for residents 7, 63, 75, and 85 have been reviewed and modified to correctly reflect the residents' condition at the time of the assessment periods. Modifications have been completed and submitted to MDS. 2. Sections H, M, and N were reviewed for accuracy on current residents' most recent Minimum Data Set based on his/her most recent Assessment Reference Date (ARD) and corrected where applicable. 3. The Registered Nurse Assessment Coordinator was educated by the Director of Nursing on assessment accuracy. 4. Registered Nurse Assessment Coordinator(s) and/or designee will audit 10% or a minimum of 5 completed Minimum Data Set(s) section H, M, and N weekly for 2 weeks and then monthly for 2 months. The results of the audits will be addressed at the Quality Assurance and Performance Improvement Committee for further analysis and corrective actions. 5. Date of compliance: 3/5/2025.