Inaccurate MDS Assessment of Restraint Use
Penalty
Summary
The facility failed to ensure that a resident assessment accurately reflected the use of a restraint device for one resident. Specifically, the quarterly Minimum Data Set (MDS) for a female resident with Lennox-Gastaut Syndrome, wheelchair dependence, aphasia, and gastrostomy status did not document the use of a seatbelt restraint, despite multiple observations of the resident wearing the seatbelt while in her wheelchair. The MDS indicated that no trunk restraint was used, and there was no active physician order for the seatbelt in the electronic medical record (EMR) at the time of review. Documentation within the resident's care plan and other scanned documents confirmed the medical need for the seatbelt, with consent from the resident's mother and signatures from the interdisciplinary care team, including a physician. Staff interviews revealed that the resident used the seatbelt every time she was in her wheelchair, and the MDS nurse acknowledged awareness of this ongoing use. However, the MDS was completed based on the medication administration record (MAR), which did not include an order for the seatbelt, leading to inaccurate reporting. Facility policy required documentation of restraint use and release in the clinical record, which was not consistently followed.