Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents, resulting in the transmission of incorrect data to CMS regarding their health status. For one resident with chronic respiratory failure and obstructive sleep apnea, the Discharge MDS did not indicate the use of oxygen therapy, despite physician orders and oxygen saturation monitoring flowsheets confirming that oxygen therapy was administered during the lookback period. The Director of Nursing (DON) acknowledged that the MDS should have reflected the oxygen therapy and that the absence of this information led to the lack of a corresponding care plan for oxygen therapy. For another resident with multiple myeloma, cauda equina syndrome, and chronic kidney disease, the Discharge MDS failed to accurately report significant weight loss and the presence of a stage 4 pressure sore. The resident's weight records showed fluctuations, including a loss of more than 5% in one month, which was not captured in the MDS. Additionally, weekly skin integrity assessments documented a stage 4 pressure sore at discharge, but this was not reflected in the MDS. The DON confirmed these omissions and stated that the MDS should have included the most current weight and the presence of the pressure sore. Facility policies required all MDS assessments to be accurate and all services provided to be documented in the medical record. The DON stated that the MDS guides the resident's plan of care and that inaccuracies in the MDS could affect the care provided. The findings were based on observation, interview, and record review, and the facility's own policies were not followed in these cases.