Inaccurate MDS Assessments for Medication Administration
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for five residents, as required by the Resident Assessment Instrument (RAI) User's Manual. For several residents, the MDS assessments did not accurately reflect medications administered during the seven-day look-back period. Specifically, residents who received daily doses of aspirin, an anti-platelet medication, were incorrectly coded as not having received anti-platelet therapy. Additionally, a resident who received Clobazam, an anti-anxiety medication, was not coded as having received such medication, and another resident who received triple antibiotic ointment for a wound was not coded as having received an antibiotic medication. These inaccuracies were confirmed through reviews of physician orders, Medication Administration Records (MAR), Treatment Administration Records (TAR), and staff interviews. The discrepancies were identified for residents who had clear documentation of medication administration during the assessment periods, but whose MDS assessments did not reflect this information. The Director of Nursing and the Nursing Home Administrator confirmed the inaccuracies during interviews.