Inaccurate MDS Documentation of Restraint Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment entries accurately reflected a resident's use of restraints. Specifically, for a resident admitted with chronic obstructive pulmonary disease and dysphagia with a gastrostomy, the MDS dated 5/15/2025 indicated that the resident did not have any restraints. However, a review of the resident's physical restraint evaluation dated 5/10/2025 showed that staff had initiated an abdominal binder restraint for the resident. During interviews and record reviews, one registered nurse stated that she did not mark the abdominal binder as a restraint on the MDS because she did not consider it to be a restraint. Another registered nurse and the Assistant Director of Nursing both confirmed that the abdominal binder used for the resident was considered a restraint and should have been documented as such on the MDS. The staff acknowledged the importance of accurate MDS entries, as they reflect the care provided and are essential for identifying the correct status of the patient. Facility policy and procedure documents reviewed indicated that any person completing any portion of the MDS assessment is required to sign and certify the accuracy of that portion. The failure to accurately document the use of a restraint on the MDS for this resident resulted in a deficiency related to the accuracy of assessments, as required by federal regulations.
Plan Of Correction
F 641 Corrective action: A. Resident #2's Admission/Medicare 5-day assessment with an Assessment Reference Date (ARD) of 05/15/2025 has been modified on 07/10/2025 to correct coding for Section P0100D. Other Restraint, to code use of the abdominal binder. This assessment was transmitted and accepted on 07/11/2025 accordingly. B. In-service was done by the Regional MDS consultant re: Section P coding accuracy on 07/9/2025. Identification of Others at Risk: The Lead MDS nurse did a chart audit on 7/10/25 and reviewed residents with current order for abdominal binder use to check if they were correctly coded on the MDS assessment/s: Section P. A copy of this audit was provided to the DON/Administrator for review. One other resident was identified for this deficient practice and MDS assessment was modified accordingly. Measures to prevent recurrence: The Lead MDS nurse will ensure all residents with (new) abdominal binder order that meet the definition of restraint are coded accurately. The Regional MDS consultant shall perform random chart audits, focusing on coding Section P accurately, monthly for three months and present inaccuracy findings to the DON and the Administrator for corrective actions. Monitoring Performance: The Director of Nursing will present a recapitulation of findings of the random monthly audits at the Monthly Quality Assessment and Assurance Committee meeting for review with corrective actions, as indicated. Measures to prevent recurrence: The Lead MDS nurse will ensure all residents with (new) abdominal binder order that meet the definition of restraint are coded accurately. The Regional MDS consultant shall perform random chart audits, focusing on coding Section P accurately, monthly for three months and present inaccuracy findings to the DON and the Administrator for corrective actions. Monitoring Performance: The Director of Nursing will present a recapitulation of findings of the random monthly audits at the Monthly Quality Assessment and Assurance Committee meeting for review with corrective actions, as indicated.