Inaccurate MDS Assessments for Medications, Diagnoses, and Incidents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for several residents, resulting in incomplete or incorrect documentation of medications, diagnoses, and incidents. For one resident with a history of stroke, hypertension, and congestive heart failure, the most recent MDS assessment did not reflect the use of antiplatelet and anticoagulant medications, despite current physician orders and medication administration records confirming daily administration of these drugs. Another resident with dementia and anxiety experienced multiple falls within the assessment period, but these incidents were not recorded on the corresponding MDS assessment. Additionally, a resident with diabetes, depression, and hypertension had an MDS assessment that failed to accurately document the administration of insulin injections and the use of an anticonvulsant, even though medication records showed consistent administration during the look-back period. In another case, a resident with a diagnosis of malignant melanoma did not have cancer documented on the most recent MDS assessment, despite the diagnosis being present in the clinical record and confirmed by the resident. Interviews with MDS staff confirmed that these omissions were errors and that the information should have been included in the assessments.