Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents, as identified through clinical record reviews and staff interviews. For one resident with chronic respiratory failure and atrial fibrillation, the MDS assessment did not reflect the administration of anticoagulant medications during the required seven-day look-back period, despite documentation in the Medication Administration Record showing that anticoagulants were given. The registered nurse assessment coordinator (RNAC) confirmed the inaccuracy of this assessment. Another resident with dementia and peripheral vascular disease had an MDS assessment indicating active infections of a multi-drug resistant organism (MDRO) and pneumonia, but there was no clinical documentation supporting the presence of these infections during the look-back period. Additionally, a third resident with diabetes had an MDS assessment stating no insulin was administered, while the Medication Administration Record showed multiple insulin injections during the same period. In each case, the RNAC confirmed the MDS assessments did not accurately reflect the residents' clinical status.