Inaccurate MDS Assessments for Medications and Treatments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents. For one resident, Section N (Medications) of the MDS assessment indicated that the resident was not on an antipsychotic medication during the seven-day review period, while a review of the Medication Administration Record showed that the resident did receive lurasidone, an antipsychotic, during that time. For another resident, Section O (Special treatments, procedures, and programs) of the MDS assessment indicated that the resident did not receive tracheostomy care during the seven-day review period, but the Treatment Administration Record confirmed that tracheostomy care was provided during that period. These discrepancies were confirmed during an interview with the Registered Nurse Assessment Coordinator, who acknowledged that the MDS assessments did not accurately reflect the residents' actual care and required modification. The deficiency was cited under CFR 483.20(g) for accuracy of assessments, and it was noted that this issue had been previously cited.
Plan Of Correction
- Resident 27's MDS was modified to indicate the use of an anti-psychotic medication during the seven-day review period. - Resident 18's MDS was modified to reflect tracheostomy care received during the seven days look-back period. - MDS of current residents on anti-psychotic medications and residents with tracheostomy care within the past 90 days were reviewed for accuracy. MDS coordinators were re-educated on accuracy of MDS. Random audits will be completed by NHA/Designee on the accuracy of the MDS of the residents who are currently on antipsychotic medications and tracheostomy care. Weekly x4, Monthly x2, with results to QAPI committee.