Inaccurate MDS Assessments for Mobility, Hearing, and Insulin Use
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) comprehensive assessments were accurately completed for two residents. For one resident with a history of stroke, hemiplegia, and hearing loss, the MDS assessment inaccurately documented that the resident had no impairment in range of motion or functional limitation to upper and lower extremities, and that the resident could hear with minimal difficulty. Observations and interviews revealed that the resident was unable to move his left arm, had minimal movement in his left leg, and could only hear when spoken to loudly and in close proximity, even with a hearing aid. The MDS coordinator acknowledged that the assessment did not reflect the resident's actual mobility and hearing status and admitted to not assessing the resident directly. For another resident with diagnoses including metabolic encephalopathy, dementia, and bipolar disorder, the MDS assessment indicated that the resident received insulin injections. However, a review of the medical record showed no physician's orders or documentation of insulin administration during the relevant period. The MDS coordinator confirmed that this was a coding error and that the resident had not received insulin. These inaccuracies in the MDS assessments were identified through record review and staff interviews.