Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for three residents, resulting in discrepancies between the residents' actual care needs and what was documented. For one resident with a diagnosis of obstructive sleep apnea, the MDS did not indicate the use of a CPAP machine, despite physician orders, care plan documentation, and staff confirmation that the resident used a CPAP at night. The facility did not provide a policy on accurate MDS assessment. Another resident with major depressive disorder and a history of stroke had inconsistencies in the MDS regarding oral and vision care. The MDS documented no dental or vision issues, while the care plan and resident interview revealed significant dental problems, a need for mouth care assistance, and a visual deficit. The resident reported never being assessed by a dentist and not having eyeglasses, despite needing them, and observations confirmed broken teeth and visual impairment. A third resident with schizophrenia and anxiety was incorrectly documented in the MDS as receiving insulin, hypoglycemic medication, and using a non-invasive mechanical ventilator. However, the care plan, physician orders, and resident interview confirmed that the resident had never received insulin, was not diabetic, and had only used oxygen via nasal cannula. The facility did not provide a policy on accurate MDS assessment for any of the cases.