Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents. For one resident with a history of schizoaffective disorder and anxiety disorder, the annual MDS did not accurately reflect the resident's positive Level II PASARR status, despite the resident having active diagnoses of anxiety disorder and schizophrenia. MDS coordinators confirmed during interviews that the resident's PASARR status should have been indicated on the MDS. For another resident with end stage renal disease, dependence on renal dialysis, dysphagia, and a gastrostomy, the quarterly MDS failed to document the presence of a feeding tube and dialysis treatment, even though the care plan and physician orders indicated the resident was receiving both tube feeding and dialysis. Interviews with the MDS coordinators, DON, and Executive Director confirmed that these treatments should have been coded on the resident's MDS. The facility's policy requires accurate coding and assessment as per CMS RAI MDS 3.0 Manual guidelines.