Inaccurate Resident Assessments Documented in MDS
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the actual status of six residents, as identified through clinical record reviews and staff interviews. For one resident, the Minimum Data Set (MDS) assessment incorrectly indicated the use of an anticoagulant, despite no evidence in the clinical record that the medication was prescribed or administered during the assessment period. Staff confirmed this was a coding error. In another case, a resident was marked as having used a limb restraint, but staff interviews revealed that the resident had never utilized such a restraint, indicating another MDS coding error. Additional inaccuracies were found in the assessments of other residents, including two residents who were incorrectly documented as having impairments of their lower extremities, and two residents who were marked as having used trunk restraints, though staff confirmed these restraints were never used. These errors were confirmed by registered nurse assessment coordinators during interviews, and the Director of Nursing was made aware of the discrepancies. The deficiencies were cited under federal and state regulations regarding the accuracy of resident assessments and nursing services.