Inaccurate MDS Assessments and Documentation Errors
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for six residents, resulting in incorrect documentation of critical assessment information. Specifically, several residents with documented PASRR Level II evaluations indicating serious mental illness or related conditions were inaccurately coded in their MDS assessments as not having such evaluations. For example, one resident with intrahepatic bile duct cancer had a completed PASRR Level II, but the admission MDS assessment did not reflect this. Another resident with diagnoses including senile degeneration of the brain, PTSD, and personality disorder had a PASRR Level II confirming severe mental illness, yet the MDS assessment was marked as not having a PASRR Level II. Similar discrepancies were found for residents with dementia, PTSD, depression, and other neurocognitive disorders, where the MDS assessments failed to accurately document the presence of PASRR Level II evaluations. Additionally, the facility did not accurately document the use of safety devices. One resident with hypertension and chronic obstructive pulmonary disease was observed wearing a wanderguard, but the corresponding MDS assessment indicated that the device was not in use. Staff interviews confirmed that these inaccuracies were due to misinterpretation of assessment questions and oversight during the completion of the MDS. These documentation errors were identified through record reviews and staff interviews, highlighting a pattern of inaccurate assessment entries for multiple residents.