Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for six out of 28 residents, as evidenced by discrepancies in the Minimum Data Set (MDS) documentation. For Resident R296, the MDS inaccurately indicated no current tobacco use, despite a physician's order and care plan allowing supervised smoking. Similarly, Resident R381's MDS also incorrectly noted no tobacco use, conflicting with a physician's order requiring a smoking apron. These inaccuracies were confirmed by the Licensed Practical Nurse Assessment Coordinator (LPNAC). Resident R352's MDS inaccurately included a diagnosis of schizophrenia, which was not supported by the Certified Registered Nurse Practitioner's (CRNP) notes or the resident's care plan. Additionally, Resident R413's MDS incorrectly documented the presence of an indwelling catheter, which was neither observed nor included in the resident's care plan or physician orders. The resident confirmed never having an indwelling catheter for urine, and the LPNAC acknowledged the error. Resident R458's MDS inaccurately recorded the discharge status, indicating a discharge to a short-term general hospital instead of home, as per the physician's order. Closed Resident Record CR611's MDS failed to document significant weight loss, despite the
Plan Of Correction
1. Section J of annual MDS for R296 was corrected to reflect status as a current smoker. Section 16000 of MDS for R352 was corrected, removing schizophrenia as a current diagnosis. Section J1300 of the MDS for R381 was corrected to reflect current tobacco use. Section H0100A of the MDS for R413 was corrected to reflect that no indwelling catheter was utilized. Section A2105 of the MDS was corrected for R458 to reflect discharge home. MDS for CR611 section K0300 was corrected to reflect weight loss. 2. Director of utilization review or designee will conduct an audit of all quarterly and annual assessments due for the month of February 2025 to ensure MDS assessments are coded accurately for the lookback period for tobacco use, weight loss, indwelling catheters, and schizophrenia. Discharge MDS for the month of February 2025 will be audited for correct discharge location. 3. Director of utilization review or designee will in-service assessment coordinators on ensuring the accuracy of MDS assessments. 4. Director of utilization review will audit 5 residents MDS assessments weekly for 4 weeks, then 5 residents monthly for 2 months to ensure accuracy of sections 16000, J1300, H0100A, K0300 and A2105. Audit findings will be shared with QAPI committee.