Inaccurate MDS Assessments for Insulin Administration
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for a resident, resulting in inaccurate documentation. The resident, who was admitted with multiple diagnoses including type 2 diabetes, hypertension, and vascular dementia, had discrepancies in the MDS assessments regarding insulin injections. The MDS with an Assessment Reference Date (ARD) of 02/28/2025 indicated that the resident received one insulin injection during the seven-day look-back period, while the MDS with an ARD of 12/24/2024 indicated seven injections. However, a review of the resident's physician orders showed no record of insulin injections during the entire stay at the facility. The MDS Coordinator, responsible for completing the MDS, confirmed the inaccuracies in the assessments. Despite reviewing the physician orders, the coordinator could not explain why the MDS assessments contained incorrect information about insulin administration. This discrepancy highlights a failure in accurately documenting the resident's medical treatment, which is crucial for ensuring appropriate care and treatment plans.
Plan Of Correction
Element 1: Resident #8 MDS assessment was modified to ensure correct coding of section N of the MDS. Element 2: All current residents with insulin coded on the most recent MDS were reviewed to verify accurate drug class coded, and modifications were made as necessary. Element 3: Regional MDS Coordinator to provide facility MDS coordinator and MDS nurse education on RAI manual Chapter 3, pages N1-N28, for accurate coding of Section N. Facility MDS staff provided with pharmacy reference material to identify proper drug classes of medications. MDS will verify MDS coding of section N to ensure appropriate coding of insulin medication class prior to completion. Element 4: MDS coordinator or designee will audit Section N for accurate insulin coding for 5 residents weekly x4 weeks, and then 5 residents monthly x 3 months. Audit findings will be presented to the facility QAPI Committee and will only be discontinued with substantial compliance and with approval of the facility QAPI Committee. Administrator is responsible for overall compliance.