Failure to Ensure Accurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for four out of thirteen residents reviewed. In one case, a resident was incorrectly coded as being discharged to a short-term general hospital, when documentation showed the resident was actually transferred to another long-term care facility. The MDS Coordinator admitted this was an accidental error during the assessment process. Another resident's MDS assessment inaccurately indicated that a gradual dose reduction (GDR) of an antipsychotic medication had occurred, including an incorrect date. Review of psychiatric evaluations and clinical records showed that no GDR was indicated or performed, and the date referenced did not correspond to any actual evaluation. The MDS Coordinator misunderstood the process, believing a GDR was performed with every psychiatric evaluation, and did not verify the information. A third resident's weight records showed significant fluctuations, but the MDS assessment did not accurately reflect these changes, nor was there documentation verifying the accuracy of the weights or actions taken to confirm them. The MDS Coordinator stated she only signed off on the assessments and did not verify the calculations, relying on dietary staff for accuracy. In another case, a resident was incorrectly coded as having a stage 3 pressure ulcer on admission, based on transfer documentation from another facility, without physical verification or accurate assessment by qualified staff. Interviews with nursing and administrative staff confirmed that the resident did not have a stage 3 pressure ulcer after admission, and the MDS Coordinator relied solely on previous records rather than current clinical findings.