Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for three residents accurately reflected the care and services they received. For one resident with dementia and epilepsy, the MDS did not indicate the use of oxygen therapy, despite physician orders and vital sign flowsheets confirming ongoing oxygen therapy. The MDS nurse acknowledged that the assessment was inaccurate and emphasized the importance of correct coding, especially for interventions requiring special precautions such as oxygen therapy. Another resident, admitted with schizophrenia and major depressive disorder, was incorrectly coded on the MDS as having Alzheimer's Disease, despite no medical diagnosis or cognitive impairment documented in the medical record. The MDS nurse confirmed that this error could lead to unnecessary treatments or medications for conditions the resident did not have. The MDS was supposed to be based on hospital paperwork and resident interviews, but the diagnosis was inaccurately entered. A third resident, diagnosed with malignant neoplasm of the liver and schizophrenia, was assessed on the MDS as not having any oral or dental issues. However, direct observation and resident interview revealed that the resident had no natural teeth and did not have dentures, relying on soft foods. The MDS nurse confirmed awareness of the resident's dental status and acknowledged the MDS was coded incorrectly. Facility policy required that all MDS sections accurately reflect the resident's status at the time of assessment, which was not followed in these cases.