Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for six residents, as evidenced by discrepancies between the MDS coding and the residents' actual medical records. For Resident 9, the MDS did not reflect the administration of apixaban, an anticoagulant, despite physician orders and medication administration records indicating its use. Similarly, Resident 17's MDS failed to indicate hospice care, although the resident was under hospice services as per physician orders and care plans. Resident 21 and Resident 26's MDS assessments did not reflect the administration of opioids, despite records showing they received oxycodone and tramadol, respectively. Additionally, Resident 37's MDS inaccurately coded the presence of an ostomy instead of a nephrostomy tube, which was documented in the care plan and physician orders. Furthermore, Resident 42's MDS inaccurately indicated the administration of an opioid, although there was no documented evidence of such medication being given during the assessment period. Interviews with the Registered Nurse Assessment Coordinator and the Director of Nursing confirmed these inaccuracies in the MDS assessments. These discrepancies highlight a failure in accurately reflecting the residents' medical status and treatments in the MDS assessments, as required by the Long-Term Care Facility Resident Assessment Instrument User's Manual.
Plan Of Correction
Minimum Data Set (MDS) assessments were updated for residents #9, 17, 21, 26, 37, 42 and resubmitted. Residents who have a Minimal Data Set (MDS) completed and require coding related to care needs have the potential to be affected. Director of Nursing provided education to the Minimal Data Set (MDS) Coordinator on accuracy of assessments related to coding resident abilities and care needs via Resident Assessment Instrument (RAI) manual. Monitoring will be captured through auditing Minimal Data Set (MDS) assessments for care needs and coding. Review up to 2 clinical records weekly for 4 weeks, then 4 clinical records twice monthly for 2 months. The audits will be conducted by the Director of Nursing or designee. Results of the audits will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.