Inaccurate MDS Documentation for Multiple Residents
Penalty
Summary
The facility failed to accurately document the Minimum Data Set (MDS) assessments for three of twelve sampled residents, resulting in discrepancies between the residents' actual care needs and what was recorded. For one resident with end stage renal disease who was dependent on hemodialysis, the MDS did not reflect their hemodialysis status, despite physician orders and medical records indicating regular dialysis treatments outside the facility. The MDS Coordinator acknowledged this miscoding and confirmed that the resident was indeed receiving hemodialysis at the time of the assessment. Another resident's discharge destination was inaccurately documented in the MDS. Although the discharge plan documentation showed the resident was discharged to the community, the MDS incorrectly indicated a discharge to an acute hospital. The MDS Coordinator confirmed this was a miscoding and emphasized the importance of accurate MDS documentation for care planning. A third resident, who had diagnoses including Alzheimer's disease and was dependent on self-care and mobility, was receiving oxygen therapy and had orders for suctioning. However, the MDS assessment did not indicate the use of oxygen therapy or suctioning, despite direct observation and physician orders confirming their use. Both the MDS Coordinator and the Director of Nursing stated that the MDS should have reflected the resident's actual care needs and services provided, and that inaccurate MDS documentation does not represent the care delivered to residents.