Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two residents, resulting in incorrect data being transmitted to CMS. For one resident with chronic respiratory failure, anoxic brain damage, tracheostomy, and gastrostomy, the MDS assessment did not accurately reflect the resident's receipt of Restorative Nursing Assistant (RNA) services and splint assistance. Although the resident was documented and observed to be receiving RNA services seven days a week, including passive range of motion exercises and splint application, the MDS indicated only five days of RNA services and no splint assistance. This discrepancy was confirmed during interviews with the MDS nurse and Director of Nursing, who acknowledged the importance of accurate MDS coding for care planning. Another resident with a history of nicotine use, anemia, and abnormal posture was also affected by inaccurate MDS documentation. The resident's Smoker Risk Assessment indicated ongoing tobacco use requiring staff supervision, but the MDS assessment incorrectly coded the resident as not currently using tobacco. The MDS nurse confirmed this error during a record review and interview, noting that the MDS should have reflected the resident's current tobacco use to ensure appropriate care interventions. Facility policies require that all portions of the MDS assessment be completed and certified for accuracy by the responsible staff. Both the MDS nurse and Director of Nursing emphasized the necessity of accurate MDS assessments to ensure that resident needs are properly identified and addressed in the plan of care. The deficiencies were identified through interviews, record reviews, and direct observation, demonstrating a failure to follow established procedures for accurate resident assessment documentation.