Inaccurate MDS Assessments for Pressure Devices and Diet Orders
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the use of pressure relieving devices and mechanically altered diets for three residents. For one resident with a history of pressure ulcer, morbid obesity, and diabetes, the MDS did not indicate the presence of a specialty mattress, despite documentation and observation confirming its use for several months. The Director of Nursing confirmed that the MDS assessment did not accurately reflect the use of the pressure reducing device. Another resident with Alzheimer's disease, malnutrition, and other chronic conditions was assessed on the MDS as not receiving a mechanically altered diet, even though dietary records, meal tickets, and staff interviews confirmed the resident was receiving a mechanical soft diet with double protein portions and fortified foods. There was also a lack of clear documentation regarding the diet order change, and staff were uncertain about the current diet order until it was updated in the electronic medical record during the survey. A third resident with multiple pressure ulcers, a recent amputation, and cognitive impairment was not documented on the MDS as having pressure relieving devices or being scheduled for turning and repositioning, despite observations and staff interviews confirming the use of a low air loss mattress, pressure relieving cushion, heel protector, and regular repositioning. The MDS Coordinator acknowledged that the MDS did not accurately reflect the resident's use of these devices and interventions.