Inaccurate Resident Assessments for Diagnoses and Treatments
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current status of four residents in areas including psychiatric diagnosis, skin conditions, dialysis treatment, and respiratory care. For one resident with a documented history of schizophrenia and a current prescription for Aripiprazole, the Minimum Data Set (MDS) admission assessment did not record an active diagnosis of schizophrenia, despite supporting documentation from the discharging hospital and physician orders. Staff responsible for MDS completion expressed uncertainty about the requirements for documenting this diagnosis. Another resident with a history of skin disorders and a dermatologist-confirmed diagnosis of Prurigo Nodularis, presenting with visible rashes and lesions, was not coded for any skin problems in the MDS quarterly assessment. Staff stated they did not code for rashes and were unaware of the lesions. Additionally, a resident with end stage renal disease and active physician orders for dialysis was not documented as receiving dialysis treatments in the MDS quarterly assessment, which staff attributed to human error. Similarly, a resident with chronic respiratory failure and obstructive sleep apnea, who had a physician order for nightly CPAP use, was not documented as using CPAP in the MDS. Staff again cited human error for the omission. These findings were based on interviews, record reviews, and direct observations, demonstrating a pattern of incomplete or inaccurate resident assessments.