Inaccurate MDS Assessment for Major Injury
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident, specifically regarding the documentation of a major injury. The resident, who had been readmitted from an acute care hospital, reported having broken his right bone after a fall while coming out of the bathroom. Despite this incident, the MDS Discharge Assessment and the 5-day assessment did not reflect the resident's status of having a major injury. This discrepancy was acknowledged by the MDS Transitional Nurse responsible for completing the assessments. The MDS Transitional Nurse admitted that the assessments did not indicate the major injury status of the resident, despite having reviewed hospital documentation before completing the MDS assessment and care plan. The Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual provides specific instructions for coding major injuries, which were not followed in this case. The facility's policy requires comprehensive and accurate assessments of each resident's functional capacity, which was not adhered to in this instance.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The MDS for Resident #109 has been reviewed and corrected to accurately reflect the with major injury. The Care Plan for Resident #109 has been reviewed and updated to include interventions related to prevention and management. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents who have had a have the potential to be affected. A facility-wide audit of all current residents who experienced in the past 90 days has been conducted to ensure the MDS accurately reflects their history and any major injuries. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: On all staff responsible for MDS completion, including the MDS Coordinator and MDS Assistant, have been re-educated by Regional Nurse on the proper coding of with major injuries to include training on accurate MDS documentation, specifically regarding Section J1900 (with Injury). Also, education was provided to ensure that all hospital diagnoses, including, are promptly reviewed and incorporated into MDS assessments and care plans. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing (DON) or designee will conduct weekly audits of 3 completed MDS for accuracy in section J1900, with a focus on with major injuries, for 2 months, then monthly for at least three additional months. Audit results will be reviewed in the facility's Quality Assurance and Performance Improvement meetings, and corrective actions will be implemented as needed. Compliance monitoring will continue until sustained improvement is demonstrated, as determined by QAPI oversight. (e) Date of compliance