Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) 3.0 assessments for two residents. For one resident with a diagnosis of major depressive disorder, the quarterly MDS assessment indicated the use of an antidepressant within the seven-day look-back period. However, a review of physician orders revealed that no antidepressant medication was currently ordered or administered for this resident. The Director of Nursing confirmed that the resident had not been receiving an antidepressant at the time of the assessment, indicating an incorrect MDS entry. For another resident with multiple diagnoses including aphasia, intellectual disabilities, and a history of falls, the quarterly MDS assessment documented daily use of a floor mat alarm during the look-back period. Physician orders did not include any documentation for a floor mat alarm, and direct observation confirmed the absence of such equipment in the resident's room. The Director of Nursing further confirmed that the facility did not possess or use floor mat alarms, and acknowledged that the MDS assessment had been coded incorrectly for this resident as well.