Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the clinical status of three residents. For one resident with hemiplegia and cognitive impairment, the quarterly MDS assessment did not document two unwitnessed falls that occurred since the previous assessment, despite clear evidence in the medical record. For another resident with COPD and a history of pulmonary embolism, the MDS assessment failed to indicate that the resident was receiving oxygen therapy during the assessment reference period, even though physician orders, the treatment administration record, and the care plan all confirmed ongoing oxygen use. Similarly, a third resident with morbid obesity and dependence on supplemental oxygen was also not coded as receiving oxygen therapy on the MDS, despite continuous oxygen use documented in the medical record and care plan. Interviews with the MDS Registered Nurse confirmed that the MDS assessments for all three residents were incorrectly coded, as they did not accurately reflect the residents' actual care and clinical status during the assessment periods. The facility's policy on clinical documentation standards requires timely and accurate documentation of resident information, which was not followed in these cases. These inaccuracies were identified through record reviews, staff interviews, and policy review, affecting three out of 22 residents reviewed for MDS accuracy.