Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents, resulting in incorrect documentation of their clinical status and care needs. For one resident, the MDS assessment inaccurately recorded the use of oxygen therapy, suctioning, tracheostomy care, and invasive mechanical ventilation, despite the absence of any supporting diagnoses, physician orders, or progress notes. Interviews with nursing staff and the resident confirmed that these interventions were never provided or required. Another resident's MDS assessment incorrectly indicated the use of a trunk restraint, although there were no orders, documentation, or staff recollection of restraint use, and the resident did not recall ever being restrained. A third resident's MDS assessment documented the use of external and indwelling catheters, even though the indwelling catheter had been discontinued following a surgical procedure, with no evidence of reinsertion during the assessment period. The MDS Coordinator acknowledged errors in the assessments after reviewing the cases during the survey, confirming that the information entered did not reflect the residents' actual conditions. The facility's policy requires that MDS assessments be accurate, complete, and supported by clinical documentation, in accordance with the RAI manual. However, the assessments in question were not verified against the residents' diagnoses, physician orders, medication and treatment records, or progress notes, leading to inaccurate reporting of the residents' care and treatment during the designated observation periods.