Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to accurately assess the status of three residents during the Minimum Data Set (MDS) process, resulting in incorrect documentation of their conditions. For one resident with a history of hemiplegia, chronic kidney disease, and above-the-knee amputation, the MDS incorrectly coded the use of bed grab bars as restraints, despite observations and interviews confirming the bars were used to assist with bed mobility and did not restrict movement. The care plan also indicated the grab bars were for safe repositioning, and staff confirmed the coding was inaccurate. Another resident with schizoaffective disorder, hypertension, and a history of traumatic brain injury was incorrectly documented on the MDS as having an indwelling catheter. Progress notes and staff interviews revealed the resident had removed the catheter prior to the assessment and refused reinsertion, with no physician order for a catheter present at the time of the MDS. Observations confirmed the absence of a catheter or drainage bag, and staff familiar with the resident's care verified he did not have a catheter during the assessment period. A third resident, admitted with diagnoses including intracranial hemorrhage, chronic kidney disease, and urinary retention, was assessed on the admission MDS as having a catheter, although observations and staff interviews confirmed she did not have one upon return from the hospital. Documentation showed the catheter had been discontinued prior to readmission, and no evidence of a catheter was found during the assessment. The MDS coordinator relied on nurse documentation and resident observation but failed to accurately reflect the resident's current status.