Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for two residents, leading to discrepancies in their documented status. Resident 9, diagnosed with Multiple Sclerosis and neurogenic bladder, had a physician's order for a Foley catheter. However, the Quarterly MDS inaccurately indicated that the resident was occasionally incontinent of urine, which was confirmed as an error by the Director of Nursing during an interview. This misrepresentation of the resident's continence status was due to incorrect coding on the MDS. Similarly, Resident 32, who had diagnoses of heart failure and chronic kidney disease, experienced an unwitnessed fall resulting in an abrasion on the left thigh. Despite this incident, the Significant Change MDS inaccurately recorded that the resident had not experienced any falls since admission or prior assessment. This error was also confirmed by the Director of Nursing, indicating a failure to accurately document the resident's fall history in the assessment.
Plan Of Correction
1. R9 and R32 MDS were corrected with accurate coding and resubmitted with modifications. 2. The regional care manager will complete education with the Licensed Practical Nurse Assessment Coordinator on accurate coding of identified sections of MDS per RAI guidelines and appropriate coding with emphasis on accurate coding. 3. An initial audit of MDS's will be completed for the past 30 days on identified residents. The Licensed Practical Nurse Assessment Coordinator will complete all assessments. 4. Licensed Practical Nurse Assessment Coordinator / Designee will complete an audit of 5 resident MDS submissions weekly x 4 weeks, then 5 resident MDS submissions two times monthly x 2 months. 5. When MDS is ready for submission, the Licensed Practical Nurse Assessment Coordinator will coordinate with the RN to verify accuracy of MDS prior to submission. 6. The results of the audit will be taken to the QAPI committee for review of findings and further interventions if warranted.