Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents, as identified through observations, interviews, record reviews, and policy review. For one resident with diagnoses including schizophrenia, anxiety, and depression, the annual MDS was incorrectly coded to indicate the absence of a serious mental illness, despite documentation and confirmation from the Administrator and DON that the resident was a PASARR level II and had a mental health diagnosis. Another resident, who required tube feedings due to swallowing difficulties, was inaccurately coded on the quarterly MDS as not having a feeding tube, even though the care plan and staff interviews confirmed the presence of a feeding tube. A third resident, admitted with multiple fractures, was discharged home with medications and home health services, but the discharge MDS inaccurately indicated a transfer to a short-term acute hospital. Multiple sources, including care plans, discharge summaries, and progress notes, confirmed the resident was discharged home. The Administrator acknowledged discrepancies in the MDS coding for all three cases and confirmed that the assessments did not accurately reflect the residents' conditions or discharge status, as required by facility policy.