Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments, affecting three residents. For Resident 32, the quarterly Minimum Data Set (MDS) dated February 8, 2025, inaccurately indicated that the resident was not receiving opioids, despite physician orders and medication administration records showing that the resident was prescribed and received Oxycodone HCl 5 mg daily, except on two specific days in April 2025. This discrepancy was confirmed through an interview with a licensed employee. For Residents 52 and 67, their quarterly MDS assessments inaccurately listed an active diagnosis of multi-drug resistant organism (MDRO). However, a review of their active diagnosis lists showed no evidence of such a diagnosis. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that neither resident had a current MDRO diagnosis, and the MDS assessments were inaccurate. These findings indicate a failure to maintain accurate clinical records as required.
Plan Of Correction
1. Resident 32, Resident 52 and Resident 67 MDS's were corrected at time DOH surveyor presented issue to MDS Coordinator and NHA. 2. MDS Coordinator performed an audit of all current and open resident MDS's to ensure accuracy. No further discrepancies noted. 3. NHA, or designee, will re-educate MDS Coordinator to ensure accurate MDS's are completed and submitted. 4. NHA, or designee, will perform weekly random audits for two weeks, then monthly random audits for two months for accuracy before submission. Results of audits will be presented at monthly Quality Assurance and Improvement Plan meetings for review and recommendations.