Inaccurate MDS Assessments for Medication Administration
Penalty
Summary
Laurel View Village was found to be non-compliant with the requirements of 42 CFR Part 483, Subpart B, specifically regarding the accuracy of Minimum Data Set (MDS) assessments for four residents. The facility failed to accurately code the administration of specific medications in the MDS assessments. For Resident 15, the MDS assessment did not reflect the administration of a diuretic medication, Valsartan-hydrochlorothiazide, despite physician orders and Medication Administration Records (MARs) indicating daily administration. Similarly, Resident 23's MDS assessment failed to indicate the administration of lorazepam, an antianxiety medication, which was ordered and documented as administered four times daily. Resident 28's MDS assessment inaccurately reflected the administration of Silver Sulfadiazine cream, a topical antibiotic, which was applied daily as per physician orders and Treatment Administration Records (TARs). Additionally, Resident 38's MDS assessment did not accurately reflect the administration of carbamazepine, an anticonvulsant medication, despite documentation of its administration. These inaccuracies were confirmed through staff interviews, including with the Registered Nurse Assessment Coordinator, who acknowledged the coding errors in the MDS assessments for these residents.
Plan Of Correction
Minimum Data Set (MDS) assessment for Residents 28, 38, 23, 15 was updated and resubmitted. Residents who have a Minimum Data Set (MDS) completed and require coding related to care needs have the potential to be affected. These individuals' Minimum Data Set were reviewed for accuracy. Education will be obtained for both Nursing Home Administrator, Registered Nurse Assessment Coordinator (RNAC), the Employee responsible for completion of the assessment, and any other individuals responsible for coding and/or auditing of the Minimum Data Set. Registered Nurse Assessment Coordinator reviewed the accuracy of assessments related to coding residents' abilities and care needs via Resident Assessment Instrument (RAI) manual. Registered Nurse Assessment Coordinator (RNAC) will reference the 3.0 Drug Class Index to confirm drug class when completing Section N (N0415. High risk Drug Classes: Use and Indication) of the Minimum Data Set Version 3.0 to assist and ensure accuracy of the Minimum Data Set. Updated 3.0 Drug Class Index obtained to ensure all classifications are accurate and reflective of any new medications. Director of Compliance or Designee will ensure Compliance going forward through auditing of the Minimum Data Set. The auditing will occur at the following schedule: 2 Clinical Records weekly for 4 weeks, followed by 4 clinical records twice monthly for 2 months. On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting.