Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments, as evidenced by discrepancies in the Minimum Data Set (MDS) for three residents. For Resident 18, the quarterly MDS inaccurately indicated that the resident was receiving insulin, despite the absence of physician orders or documentation in the Medication Administration Record (MAR) confirming insulin administration. Similarly, Resident 31's MDS incorrectly noted insulin administration, which was not supported by physician orders or the MAR. These inaccuracies were confirmed through staff interviews. Additionally, Resident 52's MDS failed to reflect the presence of an unstageable pressure ulcer on the right heel, as documented in the resident's wound and skin records. The MDS inaccurately reported no unhealed pressure ulcers, contradicting the clinical documentation. These errors in the MDS assessments were confirmed by staff interviews, indicating a failure to accurately document and assess the residents' medical conditions.
Plan Of Correction
The following Resident Assessments were resubmitted for accuracy: Resident 18 Quarterly MDS 12/17/2024 was modified and resubmitted on 1/21/2025. Resident 31 Quarterly MDS 12/6/2024 was modified and resubmitted on 1/21/2025. Resident 52 Quarterly MDS 10/11/2024 was modified and resubmitted on 1/21/2025. An MDS audit for current residents' last assessment will be completed for resident assessments coded as receiving insulin and resident assessments coded as having wounds to ensure accuracy. Any identified modifications resulting in resubmission will occur. MDS staff received re-education on MDS completion by Nursing Home Administrator on 1/21/2025, accuracy and RAI guidelines. A weekly audit of 3 quarterly resident assessments for MDS accuracy will be completed by the NHA or designee x one-month. Random audits of 3 quarterly resident assessments for MDS accuracy x 2 months will be completed by NHA or designee. Findings will be reported to Quality Assurance for review and recommendations as appropriate.