Inaccurate MDS Assessments for Catheter, Dental, and Fall Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed accurately for several residents, specifically regarding falls, dental status, catheter use, and continence status. For one resident admitted with an indwelling urinary catheter, nursing documentation and direct observation confirmed the presence of the catheter, yet the MDS assessment and continence evaluation incorrectly indicated no catheter use and did not rate urinary continence. There were also no documented orders for catheter care, and both MDS nurses and the Director of Nursing confirmed they were unaware the catheter remained in place. Another resident's MDS assessment failed to accurately reflect the presence of broken and missing teeth, despite the resident's report and staff confirmation of this dental status. Additionally, a third resident's MDS assessment incorrectly indicated a fall with major injury, although records and staff interviews confirmed only a minor fall with no major injury had occurred. The facility's policy requires adherence to the MDS Resident Assessment Instrument (RAI) manual for accurate assessment and documentation, which was not followed in these cases.