Inaccurate MDS Assessments for Discharge Status and Dialysis
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents. For one resident, the discharge return-not-anticipated MDS assessment inaccurately indicated that the resident was discharged to a short-term general hospital, when clinical documentation and staff interview confirmed the resident was actually discharged to another long-term care facility. This discrepancy was verified through a review of the progress note and confirmed by the Nursing Home Administrator. For another resident with a diagnosis of stage 4 chronic kidney disease, the admission MDS assessment incorrectly documented that the resident was receiving dialysis both prior to and during their stay at the facility. A review of the clinical record found no evidence of dialysis orders or treatments, and the DON confirmed that the resident had not received dialysis at the hospital prior to admission or while at the facility. These inaccuracies in the MDS assessments were identified through clinical record review and staff interviews.