Inaccurate MDS Assessments and Omitted Bed Rail Documentation
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents. For one resident with diagnoses including hypertension, end stage renal disease, and hyperlipidemia, the MDS assessment did not indicate that the resident received dialysis, despite nursing documentation and staff interview confirming that dialysis was provided. The MDS Coordinator acknowledged that the assessment should have reflected the resident's dialysis treatment. Additionally, two residents were observed using bilateral bed rails, but their MDS assessments did not indicate the use of bed rails. Both residents' care plans also lacked interventions related to bed rail use, despite observations and resident interviews confirming their use for mobility and support. The Director of Nursing stated that care plans should indicate bed rail use, but this was not documented. The facility did not ensure that staff had the requisite knowledge to complete accurate assessments as required.