Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for three residents. For one resident, the most recent annual MDS assessment did not indicate that a Level 2 Preadmission Screening and Resident Review (PASRR) had been completed, despite documentation showing the PASRR was completed previously. Another resident's quarterly MDS assessment failed to document a urinary tract infection (UTI) in the last 30 days, even though the clinical record and physician's orders showed the resident had been treated with antibiotics for a UTI during that period. Additionally, a third resident's quarterly MDS assessment incorrectly indicated that the resident received an antibiotic during the 7-day look-back period, but there was no physician's order for an antibiotic in the clinical record for that timeframe. The MDS Coordinator acknowledged these errors during interviews, confirming that the PASRR, UTI, and antibiotic use were not accurately coded in the MDS assessments for the respective residents.