Inaccurate MDS Assessment for Insulin Administration
Penalty
Summary
The facility failed to conduct an accurate and comprehensive assessment for one resident, as required by federal regulations. Specifically, the Minimum Data Set (MDS) assessment for the resident incorrectly indicated that she was receiving insulin and injections, despite no physician's orders for such treatments and the resident's own statement that she had never received insulin. The resident's diagnoses included acute respiratory failure with hypoxia, diabetes, depression, and white matter disease, but her diabetes was managed without insulin, and she was reportedly doing well at the time of the assessment. Interviews with facility staff revealed that the LVN responsible for completing the MDS assessments was unsure whether the resident had received insulin or injections during the relevant period and acknowledged that if a resident was not receiving these treatments, the MDS should not reflect otherwise. The administrator and DON both stated their expectation that MDS assessments be completed accurately and confirmed that the RUG score, which is influenced by the MDS, determines facility reimbursement. Both also acknowledged that an inaccurate MDS could result in incorrect billing. A review of the facility's policy confirmed that comprehensive assessments must be completed within specified timeframes and must accurately reflect the resident's functional capacity and care needs. In this case, the inaccurate coding on the MDS assessment did not align with the resident's actual care and treatment, as documented in her records and confirmed by interviews, resulting in a deficiency related to the accuracy of resident assessments.