Inaccurate MDS Assessments for Dialysis and Oral Status
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents. For one resident admitted with end stage renal disease and a displaced lower right leg fracture, physician orders indicated the need for dialysis three times a week since admission. However, multiple MDS assessments, including admission and quarterly assessments, did not document that the resident was receiving dialysis services in section O. The MDS coordinator acknowledged that dialysis was missed in the assessments due to not verifying this information during the look-back period, despite the resident and staff confirming ongoing dialysis treatments. For another resident admitted with diagnoses including alcoholic cirrhosis, chronic hepatic failure, and liver cell carcinoma, the admission assessment inaccurately indicated the presence of natural teeth and did not document the resident as edentulous in section L. Observations and interviews with the resident, LPN, and DON confirmed the resident had no natural teeth upon admission and required dentures. The MDS coordinator stated that the assessment relied on chart reviews rather than a direct visual assessment, leading to the inaccurate documentation of the resident's oral status.