Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents. For one resident, the MDS assessment incorrectly listed a diagnosis of psychotic disorder, despite clinical records and a psychiatric evaluation indicating diagnoses of adjustment disorder and unspecified dementia with behavioral disturbances, but no psychotic disorder. The Assistant Director of Nursing confirmed that the MDS was coded inaccurately for this resident. For another resident, the MDS assessment failed to indicate that the resident was receiving hospice services, even though physician orders and medical records showed that hospice care was provided continuously during the assessment period. The Assistant Director of Nursing confirmed that the MDS assessment was completed inaccurately regarding hospice services. The Nursing Home Administrator acknowledged that the facility did not ensure the accuracy of MDS assessments for these two residents.