Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents. For one resident, interviews and record reviews revealed that she was edentulous and required dentures, but her Admission MDS did not reflect her lack of natural teeth. The MDS Coordinator was unaware of the resident's dental status at the time of assessment and confirmed that the information was not accurately entered. For another resident, physician's orders and medication administration records showed that the resident was receiving daily haloperidol, an antipsychotic medication, over several months. However, the Quarterly MDS inaccurately documented that the resident had not received any antipsychotic medications. The MDS Coordinator confirmed the resident was receiving haloperidol and acknowledged the omission on the MDS assessment.