Inaccurate MDS Assessments for Pressure Injuries and Discharge Status
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for two residents. For one resident admitted with rhabdomyolysis and multiple unstageable pressure injuries, the admission MDS did not accurately reflect the correct number of pressure injuries present on admission. The Treatment Nurse confirmed the resident had five pressure injuries upon admission, but the MDS assessment did not match this information. The MDS Assistant Coordinator admitted to not verifying the number of pressure injuries with the Treatment Nurse during the assessment process, and the MDS Coordinator confirmed the inaccuracy in the recorded data. For another resident admitted for rehabilitation following hip surgery, the discharge MDS inaccurately documented the resident's discharge status. Although the resident was discharged home with family and home health physical therapy, the MDS indicated a discharge to an acute hospital. The MDS Assistant Coordinator confirmed the error after reviewing the records and acknowledged that the documentation did not reflect the resident's actual discharge destination. Facility policy requires that assessments be completed by knowledgeable staff and that all portions of the MDS be attested to for accuracy.