Inaccurate MDS Assessment for Resident with Indwelling Urinary Catheter
Penalty
No penalty information released
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Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident admitted with an indwelling urinary catheter. The resident, who had diagnoses including neurogenic bladder, severe morbid obesity, and diabetes, was admitted with an indwelling urinary catheter as documented in the clinical record and physician's orders. However, the admission MDS assessment did not indicate the presence of the catheter, despite the Resident Assessment Instrument (RAI) Manual requiring documentation of an indwelling urinary catheter if used at any time in the seven days prior to the assessment date. This discrepancy was confirmed through record review and staff interview.