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 male resident with a history of paranoid schizophrenia and severe cognitive impairment, the quarterly MDS assessment incorrectly indicated the presence of a feeding tube, despite documentation and staff interviews confirming that he had not had a feeding tube for several years. The resident's care plan did not address a feeding tube, and both the MDS Coordinator and ADON acknowledged the error, attributing it to a mistake in coding. For a female resident with multiple sclerosis and intact cognition, the quarterly MDS assessment inaccurately documented the use of a restraint. In reality, the resident used a transfer assist bar to aid with movement, which was not considered a restraint according to facility staff and regional case mix personnel. The resident's care plan described the use of hand hoops and transfer bars for positioning and self-care, but not as restraints. Staff interviews confirmed the coding error and emphasized the importance of accurate assessments for proper care planning.