Inaccurate Completion of MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for four residents, as required by the Resident Assessment Instrument (RAI) User's Manual. For one resident with a seizure disorder and cerebral palsy, the MDS did not accurately reflect the administration of an anticonvulsant medication during the seven-day look-back period, despite physician orders and medication administration records confirming its use. Another resident with coronary artery disease and a history of heart attack was not accurately coded for receiving an antiplatelet medication, even though both physician orders and the medication administration record indicated the medication was given during the assessment period. These inaccuracies were confirmed by the Director of Case Management. Additionally, a resident who was readmitted to the facility after a hospital stay for a hip fracture was not properly coded in the MDS to indicate this was the first assessment since reentry, which prevented the documentation of a recent fall and fracture. Another resident's discharge status was incorrectly recorded in the discharge tracking MDS, with the record indicating a discharge to the hospital instead of a personal care home, as documented in the nursing notes. These errors were also confirmed by the Director of Case Management.