Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the current status of two residents. For one resident with diabetes mellitus and pulmonary embolism, the MDS assessment incorrectly documented the use of an anti-platelet medication, while clinical records and physician orders indicated the resident was receiving an anti-coagulant medication (dabigatran). For another resident with end stage renal disease and chronic congestive heart failure, clinical records, progress notes, and direct observation confirmed the resident was on chronic oxygen therapy via nasal cannula, but the MDS assessment did not indicate that the resident was receiving oxygen therapy. The Director of Nursing confirmed that the MDS assessments for both residents were inaccurate and did not reflect their current clinical status.