Inaccurate MDS Assessments for Medication and Dental Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the clinical status of two residents. For one resident, the quarterly MDS assessment indicated that the resident received an insulin injection during the seven-day look-back period. However, a review of the medication administration records for the relevant months showed no documented evidence that the resident received any insulin injections during that period. This discrepancy was confirmed by the Regional Nurse Consultant and the Registered Nurse Assessment Coordinator during an interview. For another resident, the annual MDS assessment did not accurately reflect the resident's dental status. The resident was observed to be edentulous, and dental consults documented the extraction of teeth and the process of obtaining dentures. Despite this, the MDS assessment did not indicate that the resident was edentulous, as required. The Regional Nurse Consultant confirmed that the MDS assessment was not accurate regarding the resident's dental condition.