Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident diagnosed with bipolar disorder and heart failure. The resident experienced a significant weight gain of 13.9% over six months, increasing from 152.4 pounds to 173.6 pounds. Despite this, the MDS assessment dated November 8, 2024, inaccurately recorded the resident's weight as 146 pounds and failed to acknowledge the significant weight gain. Additionally, the assessment incorrectly indicated that the resident did not receive antipsychotic medication during the review period, despite records showing the resident had been receiving olanzapine since May 17, 2024.
Plan Of Correction
1. The MDS of Resident 7 was modified. 2. A house wide audit was conducted by CRC for residents with completed MDS for the past 30 days to verify accuracy of coding of antipsychotic medications and weights. 3. NPE or designee will re-educate the CRC on accurate coding of antipsychotic medications and weights on the MDS. Residents scheduled for MDS completion will be reviewed during clinical meeting to verify antipsychotic and weight accuracy. 4. CRC and/or designee will conduct weekly audits of MDS completed weekly x 8, then monthly x 2 to verify accuracy antipsychotic medications and weight documentation. Audits will be reviewed at the QAPI meeting for review or recommendations.