Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status for three residents. Resident 17 experienced a significant weight loss of 31 pounds over six months, but the Quarterly MDS inaccurately marked the weight loss question as "no or unknown." This discrepancy was confirmed by the Nursing Home Administrator (NHA) and was acknowledged to be an error that required modification. Resident 28's clinical record showed conflicting information regarding weight changes following a hospital stay. Initially, a nutrition note indicated significant weight gain, but a later entry corrected this to significant weight loss. The Medicare 5 Day MDS did not reflect this weight loss, and during an interview, the dietician confirmed the MDS was inaccurately coded. Resident 58's Quarterly MDS failed to indicate the presence of a urinary catheter, despite physician orders and treatment records confirming its use. The NHA confirmed this coding error, acknowledging the need for correction.
Plan Of Correction
1. R17 quarterly MDS was corrected to reflect weight loss, R28 Medicare 5 Day MDS was corrected to reflect weight loss and R58 quarterly MDS was corrected to reflect urinary catheter. All residents reside at the facility. No adverse effects related to practice. 2. All residents have the potential to be impacted. The MDS Coordinator will conduct a facility audit of the most recent completed MDS assessments for all residents to identify correct coding of weight/loss/gain and correct coding of indwelling catheter by March 14, 2025. Any coding errors identified in the audit will be corrected as well. 3. DON and/or NHA to educate the MDS Coordinator by March 14, 2025 on Section K, Swallowing and Nutritional Status of the RAI Manual; and Section H Bowel and Bladder of the RAI Manual that includes the importance of thoroughly reviewing the medical record prior to completing the MDS Assessment. 4. Audits to be completed by the MDS Coordinator for the MDS section K and Section H on 5 residents weekly x4 then monthly for 2 months, until 100% is achieved. Findings of the audits will be reported monthly to the QAPI committee meeting to ensure compliance is obtained and maintained.