Inaccurate Resident Assessments Lead to Deficiencies in Care Planning
Penalty
Summary
The facility failed to ensure accurate assessments for residents, leading to deficiencies in care planning and treatment. For one resident, the Minimum Data Set (MDS) did not reflect a diagnosis of dementia, despite the resident being prescribed donepezil, a medication used to treat dementia. The MDS nurse acknowledged that the pre-admission paperwork did not include dementia as a diagnosis, and the physician should have been consulted to clarify the order. This oversight resulted in the absence of a resident-centered care plan for dementia, potentially affecting the resident's functional or psychosocial status. Another resident's assessment was inaccurate as the MDS did not indicate the use of a home continuous positive airway pressure (CPAP) machine, despite the resident having obstructive sleep apnea and using the CPAP at the facility. The MDS nurse admitted not seeing the CPAP during the assessment, and staff failed to report its presence, leading to the lack of an order and care plan for its use. This omission could delay necessary care and treatment for the resident. Additionally, the facility did not accurately code a resident's MDS to reflect their legal name as it appears on government-issued identification. This discrepancy was noted across multiple assessments, and the Director of Nursing emphasized the importance of entering the correct legal name to ensure accurate billing and service delivery. The facility's policy on accuracy of assessments was not adhered to, resulting in potential impacts on the resident's plan of care and delivery of necessary services.
Plan Of Correction
C. What measures will be put into place or what systematic changes the facility make to ensure that the deficient practice does not recur; The MDS Consultant/designee will re-educate the MDS Nurse and MDS support staff on the facility policy and procedure Resident Assessment Instrument, with emphasis on accurate completion of the MDS including section I active diagnoses. The MDS nurse will work with the business office to obtain the residents' government issued ID/common working file in order to accurately reflect the residents' legal name. D. How the facility plans to monitor its performance to make sure solutions are sustained; The Medical Records Director/designee will monitor MDS accuracy of section I and the residents' active diagnosis list for five records monthly for three months. The Medical Records Director/Designee will get the common working file/government ID of all patients to audit the accuracy of name once a month. Concerns identified will be reported to the Director of Nursing and MDS Nurse for immediate completion of modification assessment and submission to QIES. The Director of Nursing/designee will report trends identified in the Medical Records audits to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee recommended interventions to ensure continued compliance with this plan of correction; and potential termination of this plan of correction when substantial compliance has been met. Substantial compliance shall be indicated at the discretion of the QAA Committee following three consecutive evaluations of MDS audit reports without findings of a variance to standard. Allegation of Compliance Date 3/25/2025. F 641 A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident 68's diagnosis of dementia was added to her comprehensive assessment and care plan on 1/29/25. Resident 68's antipsychotic was discontinued on 2/14/25. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; All residents have the potential to be affected by the facility practice. C. What measures will be put into place or what systematic changes the facility make to ensure that the deficient practice does not recur; The MDS Consultant/designee will re-educate the MDS Nurse and MDS support staff on the facility policy and procedure Baseline Care Plan with emphasis on diagnosis and medication care planning on 3/24/25. The IDT will review the baseline care plan of newly admitted the following business day to ensure the plan includes the necessary information to care for the resident including diagnoses which may affect the resident's psychosocial well-being and psychotherapeutic medications which may affect the resident's quality of life.