Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents, as required by the Resident Assessment Instrument (RAI) manual and the facility's own policy. For one resident, the admission MDS indicated that insulin injections were administered for all seven days of the assessment look-back period, despite a review of the electronic medical record (EMR) and Medication Administration Record (MAR) showing no insulin orders or administration. The resident also confirmed during an interview that she did not use insulin. MDS coordinators reviewed the record and acknowledged that the insulin was incorrectly coded on the MDS. For another resident, the discharge MDS was inaccurately coded as a discharge to a short-term general hospital, while progress notes and a follow-up call indicated the resident had actually been discharged home and was receiving physical therapy locally. MDS coordinators and the Director of Nursing confirmed the discrepancy between the discharge location documented in the MDS and the actual discharge destination. These inaccuracies in MDS coding had the potential to affect care planning and the provision of required services.