Inaccurate MDS Assessments for Special Treatments and Procedures
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents, resulting in incorrect documentation of special treatments, procedures, and programs. For one resident with epilepsy and tracheostomy status, the MDS assessment inaccurately indicated that she received dialysis, which she confirmed she had never received. Another resident with a history of a nontraumatic brain bleed and tracheostomy was documented as using an invasive mechanical ventilator, but direct observation and staff verification confirmed that only tracheostomy care was provided, with no ventilator in use. A third resident with bladder inflammation was also incorrectly documented as receiving dialysis, which he denied ever having received. The MDS Coordinator reviewed the medical records and care plans for all three residents and verified that the MDS assessments were coded incorrectly. The Coordinator was unable to explain the reason for the inaccuracies, noting that another MDS staff member, who was responsible for the assessments, was not available to provide clarification. The facility's policy requires that all assessments accurately reflect the resident's status at the time of assessment and that each staff member certifies the accuracy of their portion of the assessment.