Inaccurate MDS Assessments for Injections, Anticoagulant, and Tobacco Use
Penalty
Summary
The facility failed to accurately assess and document the clinical status of three residents in the Minimum Data Set (MDS) assessments. One resident with a diagnosis of Type 2 Diabetes was prescribed and administered insulin injections as documented in the Medication Administration Record and physician's notes, but the MDS assessment incorrectly indicated that the resident did not receive any injections during the observation period. Another resident was prescribed and received Apixaban, an anticoagulant, as confirmed by physician orders and the Medication Administration Record, yet the MDS assessment inaccurately recorded that the resident did not receive any anticoagulant medication during the look-back period. In both cases, the MDS coordinator acknowledged the discrepancies between the clinical records and the MDS entries during interviews and record reviews. A third resident, who was documented as a smoker in the physician's notes and a smoking evaluation, and was observed both with a vaping device and smoking cigarettes on facility grounds, was incorrectly assessed in the MDS as not using any form of tobacco. The MDS coordinator confirmed the inaccuracy after reviewing the resident's records and observations. These failures to accurately assess and document the residents' clinical statuses in the MDS have the potential to result in care needs not being properly identified or addressed.