Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents. For one resident with Alzheimer's disease and dementia, documentation showed two separate incidents where the resident was found sitting on the floor, one of which involved complaints of right foot pain. Progress notes and interdisciplinary team documentation indicated no injuries were observed at the time of the falls, and subsequent notes confirmed no new wounds or injuries. However, the most recent MDS assessment inaccurately recorded the number and type of falls, indicating no falls without injury and one fall with injury, which did not align with the clinical documentation. For another resident with muscle weakness, tremors, and a history of urinary tract infections, there were inconsistencies between the resident's self-report, staff interviews, and progress notes regarding her continence status. While the resident and staff described her as usually continent with occasional incontinence, the most recent MDS assessment documented her as frequently incontinent of both bladder and bowel. The facility did not have a specific policy for MDS assessments and reported following the Resident Assessment Instrument (RAI) manual.