Inaccurate MDS Assessments for Medications and Pressure Ulcers
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents, resulting in incorrect data being transmitted to CMS. For one resident with a history of cerebrovascular accident, congestive heart failure, and hypertension, Gabapentin was ordered for neuropathic pain, but the MDS assessment did not encode this medication as an anticonvulsant under section N0415. The MDS nurse confirmed that Gabapentin should have been classified as an anticonvulsant based on its pharmacological class, regardless of the prescribed reason, and acknowledged the assessment was completed inaccurately. Another resident, diagnosed with cerebrovascular accident, left elbow contracture, and osteoarthritis, developed a stage 2 pressure ulcer on the sacrum prior to discharge. However, the discharge MDS assessment failed to record the presence of this stage 2 pressure ulcer in section M0300. The MDS nurse stated that the assessment reference date for skin conditions was seven days and admitted to providing incorrect information in the discharge assessment sent to CMS. A third resident, with diagnoses including hypertension, diabetes mellitus, and hyperlipidemia, was prescribed Eliquis, an anticoagulant, as documented in the order summary and care plan. Despite this, the MDS assessment did not reflect the resident's use of an anticoagulant. The MDS nurse confirmed the omission and stated that inaccurate assessments could affect the interventions provided to residents. Facility policy required all staff completing any portion of the MDS to attest to the accuracy of the information, but this was not adhered to in these cases.