Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for four out of five sampled residents, resulting in inaccurate documentation of their health status and care needs. For one resident, the MDS was incorrectly coded as always incontinent with urinary continence, despite the resident being alert, oriented, and able to communicate the need to use the restroom. The MDS Coordinator acknowledged that the assessment was coded incorrectly and that this could lead to an inappropriate plan of care. Another resident's MDS did not accurately reflect an active diagnosis of a mood disorder, even though psychiatric and psychological evaluations documented major depressive disorder and adjustment disorder with depressed mood, and the resident was prescribed an antidepressant. The MDS Coordinator and the Director of Nursing both confirmed that the MDS should have included the mood disorder diagnosis to ensure care plans were based on accurate information. Additionally, the MDS for a third resident failed to document the use of bed and chair sensor alarms, which were ordered and in use as safety devices. The MDS Coordinator admitted to omitting this information, and the Director of Nursing stated that such alarms should be documented in the MDS to ensure appropriate monitoring and safety. For a fourth resident, the MDS listed schizophrenia and depression as diagnoses, but psychiatric evaluations and medication orders indicated bipolar disorder and depression, with no evidence of schizophrenia. Both the MDS Coordinator and the Director of Nursing recognized the inaccuracy, noting that it could affect the resident's treatment plan.