Inaccurate MDS Assessments Documented for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of three residents. For one resident with a history of heart attack, chronic atrial fibrillation, and a language disorder, the Significant Change MDS assessment incorrectly documented that the resident was receiving hospice care, despite records showing discharge from hospice prior to the assessment. MDS staff acknowledged this was an error during interview. For two other residents with diagnoses including dementia, diabetes, high blood pressure, and heart disease, their Annual MDS assessments incorrectly indicated they were taking anticoagulant medications. Review of physician orders confirmed that neither resident was prescribed anticoagulants; instead, both were taking aspirin, an antiplatelet medication. MDS staff confirmed that the medications were incorrectly classified on the MDS forms.