Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents. For one resident, the MDS inaccurately documented the individual as a current tobacco user, despite staff confirming the resident was not a smoker. Another resident with a diagnosis of acute respiratory failure and an active physician order for continuous oxygen therapy was incorrectly recorded in the MDS as not receiving oxygen therapy, even though the care plan and staff interviews confirmed ongoing oxygen use. A third resident, admitted with multiple diagnoses including Type 2 Diabetes Mellitus, was receiving insulin injections as ordered by the physician. However, the MDS failed to document diabetes as an active diagnosis and did not correctly categorize the resident's primary medical condition. Staff interviews confirmed these were documentation errors and that the MDS did not accurately reflect the residents' current clinical status.