Failure to Accurately Complete MDS Assessments for Bedrail and Respiratory Device Use
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two residents, specifically regarding the use of bedrails and respiratory support devices. For one resident, the quarterly MDS did not indicate the use of bedrails, despite documentation and interviews revealing that bedrails were in use. The resident experienced multiple falls, resulting in fractures to both arms, and there was no documentation of family education or consent regarding bedrail use. Facility policy required assessment and documentation of bedrail use, including risks and appropriate interventions, but these steps were not followed. For another resident, the admission MDS did not reflect the use of continuous oxygen via nasal cannula or CPAP, even though these treatments were being provided. Interviews with nursing staff revealed confusion and lack of knowledge about where to find or document oxygen orders, and the absence of a DON led to incomplete assessments and missing documentation. The staff responsible for MDS completion either lacked access to necessary systems or were unaware of their responsibilities, resulting in incomplete and inaccurate resident assessments. Facility policies required comprehensive assessments to guide care planning and interventions, but these were not adhered to during the period when the DON position was vacant. Staff interviews confirmed that essential assessments, including fall and bedrail assessments, were not performed, and there was no clear delegation of responsibilities. The lack of accurate MDS documentation and failure to follow established protocols contributed directly to the deficiencies identified for both residents.