Inaccurate MDS Assessments for Tobacco Use and Restraint Coding
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of several residents regarding tobacco use and the use of restraints. For two residents with documented tobacco use, care plans and smoking evaluations indicated active use of tobacco products, including vaping, during the relevant assessment periods. However, their MDS assessments incorrectly documented that they did not use tobacco products during the 7-day look-back period. This discrepancy was identified through record review and staff interviews, which confirmed the residents' ongoing tobacco use. Additionally, for three residents with physician orders for the use of 1/4 top side rails as enablers for bed mobility and transfers, the MDS assessments inaccurately coded the use of these side rails as restraints. Staff interviews clarified that the side rails were not used as restraints and did not meet the definition of a physical restraint as outlined in the RAI Manual. The MDS Coordinator and the Director of Nursing Services acknowledged that these MDS assessments were coded in error, resulting in inaccurate documentation of the residents' status.