Inaccurate MDS Assessments for Antipsychotic Use and Resident Weights
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents. For one resident, the MDS assessment incorrectly documented that a Gradual Dose Reduction (GDR) for an antipsychotic medication was both attempted and contraindicated on the same date. Record review showed that the resident had been on Risperdal, an antipsychotic, for a neurological condition (Huntington's disease) since 2022, with no change in dosage and no documented contraindication for a GDR. The MDS Coordinator confirmed that the documentation of a contraindication was incorrect and that there had been no recent changes to the antipsychotic medication. Additionally, the discontinuation of an antianxiety medication was incorrectly associated with the antipsychotic medication in the assessment. For another resident, the MDS assessment inaccurately recorded the resident's weight. The assessment listed a weight of 134 pounds, while the most current weight in the electronic medical record prior to the assessment date was 132 pounds. The Registered Dietician (RD) stated that she obtains weights directly from the electronic medical record and uses the most recent weight before the assessment date. Upon review, the RD acknowledged the inconsistency between the documented weight in the MDS and the electronic medical record.