Inaccurate MDS Assessments for PASRR, Tobacco Use, and Anticoagulant Documentation
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of four residents, as required by facility policy and the Resident Assessment Instrument (RAI) User's Manual. For two residents with documented diagnoses of serious mental illness and positive Level II PASRR screenings, the MDS assessments incorrectly indicated that they were not considered by the state Level II PASRR process to have a serious mental illness or related condition. This was confirmed by both clinical documentation and staff interviews, which established that the residents did meet the criteria for serious mental illness according to state review. Additionally, one resident's MDS assessment failed to accurately reflect current tobacco use. Despite clinical records, physician orders, and a smoking safety screening indicating that the resident smoked 5-10 cigarettes daily and was permitted to smoke under supervision, the MDS was coded as 'No' for current tobacco use. Nursing progress notes further documented the resident's participation in smoking activities and related behavioral incidents during smoking times. For two other residents, the MDS assessments indicated that they had received anticoagulant medications during the 7-day look-back period. However, a review of their clinical records did not reveal any physician orders for anticoagulant medications, suggesting that the MDS entries were inaccurate. These discrepancies were acknowledged by the facility's LPN Assessment Coordinator during staff interviews.