Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in the documentation of their medical status. For one resident, the MDS assessment did not accurately reflect the administration of anticoagulant and diuretic medications, despite physician's orders and medication administration records indicating that these medications were given during the seven-day look-back period. This discrepancy was confirmed through an interview with the Registered Nurse Assessment Coordinator (RNAC). Additionally, the facility inaccurately coded the discharge status for two residents. One resident was discharged home with home health services, but the MDS assessment incorrectly indicated a discharge to a short-term general hospital. Another resident's death tracking MDS assessment inaccurately recorded the resident as deceased, while nursing notes confirmed the resident was sent to a hospital for further evaluation and treatment. These inaccuracies were confirmed through interviews with the Assistant Campus Director.
Plan Of Correction
Residents 69 and 96 have discharged from the facility. Resident 55 MDS was updated with appropriate coding. A facility-wide sweep of all residents meeting the requirements of anticoagulants and diuretic medications on admission assessments, discharge status in Section A2105 of discharge assessments, and accurate discharge to the hospital minimum data set (MDS) tracking's were opened were completed going back to February 1, 2025. Any issues identified were corrected at the time of discovery. The Registered Nurse Assessment Coordinators (RNAC) was re-educated regarding the resident assessment instrument (RAI) Manual for Section N: Medications and Section A: Identification Information. The Nursing home administrator (NHA) or designee will conduct audits to ensure that Admission MDS assessments with anticoagulant and diuretics coded were completed correctly per the RAI Manual, and discharge assessments will have accurate discharge tracks and locations completed correctly per the RAI Manual required schedule weekly X4 weeks, then monthly X2 months. Identified issues will be addressed at time of discovery. Audit results are reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education/re-education.