Inaccurate MDS Assessments for Discharge, Medication, and Falls
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, resulting in incorrect documentation of discharge status, medication administration, and fall history. For one resident, the discharge MDS was coded as a transfer to an acute hospital, despite physician orders and staff confirmation that the resident was discharged home with medications and home health services. This discrepancy was verified during a record review and interview with the Minimum Data Set Manager, who acknowledged the error and confirmed the resident was not discharged to a hospital as recorded. For another resident, the MDS assessment failed to document the use of injectable medication, despite physician orders and electronic medication administration records showing weekly subcutaneous injections for diabetes. Additionally, the MDS inaccurately recorded the resident's fall history, listing both a fall with no injury and a fall with injury, when only a fall with no injury was documented in the incident reports. These inaccuracies were confirmed by the Minimum Data Set Coordinator Manager and the Director of Nursing during interviews and record reviews, who both stated that the MDS assessments should have been completed accurately according to facility policy and the RAI Manual.