Inaccurate MDS Matrix and Resident Assessments
Penalty
Summary
The facility failed to ensure the accuracy and timeliness of the Minimum Data Set (MDS) Matrix for three out of eight sampled residents. For one resident, the matrix incorrectly indicated the use of anticoagulant medication, despite the resident having discontinued the medication several months prior, as confirmed by both the resident and a review of medical records. Another resident was incorrectly listed as receiving antibiotics, although the antibiotic therapy had been discontinued, and the resident confirmed not currently taking any antibiotics. The MDS Coordinator acknowledged that the matrix was not updated as required and admitted to not having updated it in time. Additionally, the facility failed to accurately code a resident's significant weight loss on both the MDS and the Resident Matrix. The matrix did not reflect excessive weight loss without a prescribed weight loss program, and the MDS inaccurately indicated that the resident was on a prescribed weight loss regimen. However, documentation and interviews with the Registered Dietitian confirmed that the resident was not on a weight loss program but was instead receiving nutritional interventions to address malnutrition and pressure ulcers. The MDS Coordinator confirmed the coding error and attributed it to the inaccurate MDS assessment. The facility's policy requires accurate and timely completion of all MDS assessments and supporting documentation, but the MDS Coordinator stated that updates were generally made weekly and admitted to not updating the matrix as expected. No specific policy was provided regarding the frequency or process for updating the Resident Matrix. The deficiencies resulted in inaccurate documentation for multiple residents, including an inaccurate quarterly MDS for one resident.