Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents. For one resident, the MDS assessment incorrectly documented a diagnosis of pneumonia under active infections, despite the resident stating she had never had pneumonia while in the facility. This was confirmed by the Infection Preventionist, and the MDS Registered Nurse acknowledged the discrepancy, stating that the assessment needed revision. The nurse also indicated that there was no specific facility policy for this process, but that the Resident Assessment Instrument (RAI) was followed. For another resident, the MDS assessment failed to indicate the use of antibiotics, even though physician orders and the care plan documented ongoing prophylactic antibiotic therapy for a urinary infection. The MDS Registered Nurse confirmed awareness of the resident's antibiotic use and acknowledged the inaccuracy in the MDS documentation. The Director of Nursing stated that she expected the MDS information regarding antibiotic use to be accurate.