Failure to Accurately Document Dialysis on MDS Assessment
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for one resident who was receiving hemodialysis. According to the Resident Assessment Instrument manual, Section O is intended to document any special treatments, procedures, or programs, including dialysis, that a resident receives during the specified look-back period. Review of the facility's records and interviews confirmed that the resident regularly left the facility three times a week to receive dialysis treatment. Despite this, multiple MDS assessments for the resident, including admission and subsequent assessments, did not indicate that the resident was receiving dialysis. The MDS Coordinator/Registered Nurse verified that the dialysis treatment was not marked on the MDS, even though the resident was actively receiving it. This omission resulted in the resident's MDS assessments being inaccurate regarding their special treatments.