Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for three residents. Resident 21's Minimum Data Set (MDS) inaccurately indicated that the resident had not received hospice services, despite a physician's order and care plan confirming hospice admission. This discrepancy was acknowledged by the Nursing Home Administrator during an interview. Resident 259's MDS did not reflect the physician's documentation that a gradual dose reduction of the antipsychotic medication was contraindicated, despite a pharmacy recommendation and physician's note. This error was confirmed by both the Registered Nurse Assessment Coordinator and the Assistant Nursing Home Administrator. Resident 351's discharge MDS inaccurately recorded the discharge status as being to a short-term general hospital, while the resident had actually left the facility against medical advice and returned home. This error was confirmed by the Nursing Home Administrator, who acknowledged that the discharge MDS was marked inaccurately. These inaccuracies in the MDS assessments highlight a failure in accurately reflecting the residents' statuses, as required by the regulations.
Plan Of Correction
This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. Resident 21 MDS was corrected to reflect resident was receiving hospice services. Resident 259 MDS was corrected to reflect that the physician did document the gradual dose reduction was contradicted for the Seroquel ordered September 25th, 2024. Resident 351 MDS was corrected that showed the resident discharged from the facility AMA. 2. To identify other residents that have the potential to be affected, the NHA/designee conducted an audit on hospice residents to ensure MDS is properly coded. The NHA/designee will conduct an audit on residents with gradual dose reductions in past 30 days to ensure MDS is coded properly for physician responses. The NHA/designee conducted an audit on the past 30 days of discharges to ensure the MDS is coded properly. 3. MDS staff will be educated by staff development/ designee on the importance of accurately completing MDS assessments and documentation. 4. The NHA/designee will conduct an audit 1x a week for 4 weeks to ensure on residents on hospice services to ensure the MDS is coded properly. The NHA/designee will conduct an audit 1x a month for 3 months to ensure gradual dose reductions are coded properly based on physician documentation. The NHA/designee will conduct an audit 1x a week for 4 weeks on residents that discharge to ensure their MDS is coded properly on where they discharged. Results of the audits will be reviewed at the QAPI meeting to determine if future action/audits are needed.