Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents. For one resident, the MDS inaccurately documented that the resident received an insulin injection, when in fact the resident only received a semaglutide injection and no insulin. This was confirmed by both the Medication Administration Record (MAR) and the MDS Coordinator. For another resident, the MDS assessment failed to reflect that the resident had received Restorative Nursing Program (RNP) services, including both active and passive range of motion exercises, within the seven days prior to the assessment, despite documentation showing these services were provided. The MDS Coordinator acknowledged that these services should have been included in the assessment. Additionally, a third resident's MDS assessment inaccurately indicated the presence of a stage 2 pressure ulcer, when the resident actually had an open blister and cellulitis on the lower left leg, but no pressure wounds. This discrepancy was confirmed through review of the skin assessment, physician's orders, and interview with the MDS Coordinator. In each case, the inaccurate MDS assessments were identified through record review and staff interviews, demonstrating a failure to accurately assess and document the residents' conditions and care provided.