Failure to Accurately Assess and Document Restraints and Restorative Nursing Services in MDS
Penalty
Summary
The facility failed to accurately assess and document the use of restraints and restorative nursing services for two residents, as required by the Minimum Data Set (MDS) assessment tool. For one resident with a history of tracheostomy, gastrostomy, and acute respiratory failure, the MDS did not reflect the use of bilateral hand mittens, which were ordered and applied to prevent the resident from removing life-saving devices. Observations and staff interviews confirmed that the mittens were in use and considered restraints, but the MDS did not document them as such. The MDS Assistant acknowledged that the mittens met the definition of a restraint according to the Resident Assessment Instrument (RAI) but were not coded appropriately, which could affect the accuracy of data submitted to CMS and the resident's care assessment. For another resident with multiple complex medical conditions, including dependence on a respirator and renal dialysis, the MDS failed to document participation in a Restorative Nursing Program (RNP), despite a physician's order for active assisted range of motion (AAROM) exercises to be performed by a Restorative Nursing Assistant (RNA) three times a week. Review of records and interviews with the MDS Assistant confirmed that the RNA services were not coded in the MDS, even though the services were ordered and intended to maintain or restore the resident's physical function. The Director of Nursing confirmed that both the hand mittens should have been coded as restraints and the RNA services should have been included in the MDS assessments. Facility policy and the MDS Coordinator's job description require comprehensive and accurate assessments to develop person-centered care plans and ensure compliance with regulations. The failure to accurately assess and document these interventions in the MDS had the potential to impact the identification of care needs and the development of appropriate care plans for the affected residents.