Inaccurate MDS Assessments for Restraint Use and Bowel/Bladder Status
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two residents, resulting in deficiencies related to restraint use and bowel/bladder documentation. For one resident with dementia, difficulty walking, and muscle weakness, the MDS inaccurately indicated the use of trunk restraints. Observations and interviews with staff confirmed that the resident did not have restraints, and both the MDS Coordinator and Director of Nursing acknowledged the inaccuracy in the MDS documentation regarding restraint use. For another resident admitted with a history of antimicrobial resistance, urinary tract infection, acute kidney failure, and difficulty walking, the MDS assessment inaccurately documented the resident as frequently incontinent of bowel and bladder, and not on a bowel and bladder program. However, the care plan indicated the resident was continent, and interviews with the resident and staff confirmed the resident was generally able to control bowel and bladder function, with rare episodes of incontinence. The resident expressed a desire for scheduled reminders and assistance to the restroom, which was not reflected in the MDS or care plan alignment. Facility policy and procedure reviews confirmed the requirement for accurate resident assessments and the use of the Resident Assessment Instrument (RAI) process to ensure proper care planning. The discrepancies between the MDS assessments and actual resident status had the potential to result in inadequate care, as acknowledged by facility staff during interviews.