Inaccurate MDS Assessment of Insulin Administration
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment entries accurately reflected a resident's insulin status. Specifically, the MDS for a resident, completed on 2/19/2025, indicated that the resident received one injection of insulin during the seven-day look-back period. However, a review of the resident's medical chart and interview with the MDS Coordinator revealed that the insulin order had been discontinued on 2/6/2025, prior to the look-back period. This resulted in inaccurate documentation on the MDS regarding the resident's insulin administration. The resident involved had a medical history including congestive heart failure, hypertension, and diabetes mellitus, and was dependent on staff for several activities of daily living. Both the MDS Coordinator and the Director of Nursing confirmed that the MDS is used to guide care planning and that inaccurate entries could lead to an incorrect care plan. The facility's policy required comprehensive assessments to be conducted according to established criteria and timeframes, but this was not followed in this instance.