Inaccurate MDS Assessments and Missed Risk Evaluations
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the clinical status of several residents, resulting in multiple deficiencies. For one resident with a history of cerebrovascular disease, neuropathy, and dementia, the quarterly MDS did not document a stage 3 pressure ulcer that was present and facility-acquired, nor was a Braden scale risk assessment completed quarterly as required. Interviews with nursing staff and record reviews confirmed that the pressure ulcer was omitted from the MDS and that the last Braden assessment had not been updated for several months. Another resident with severe cognitive impairment and multiple comorbidities experienced two falls prior to the quarterly MDS assessment, but these incidents were not documented in the MDS. Additionally, the required quarterly fall risk assessment was not completed, with the last assessment dated several months prior. Staff interviews confirmed the omission of the falls from the MDS and the lack of timely risk assessment. A third resident with severe cognitive impairment suffered a fall resulting in a laceration and stitches, but the MDS inaccurately recorded the number of falls with injury. In another case, a resident with traumatic brain injury and reduced mobility had pressure ulcers on admission, but the quarterly MDS did not reflect the presence of these wounds. Staff interviews and record reviews consistently confirmed that the MDS assessments were inaccurate and did not align with the residents' actual clinical conditions.