Inaccurate MDS Assessments Due to Documentation and Data Entry Errors
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two of thirteen sampled residents. For one resident, the MDS assessment did not reflect the actual therapy minutes received during the seven-day lookback period, despite the resident having completed and participated in multiple therapy sessions, as confirmed by both the resident and a therapy minutes report. The MDS Coordinator acknowledged that therapy minutes are typically pulled automatically into the assessment, but due to a recent software change, the data did not transfer as expected. The Coordinator did not verify the therapy minutes with the therapy department, resulting in the omission of therapy services from the resident's MDS. For another resident with a diagnosis of diabetes mellitus, the MDS assessment incorrectly documented that the resident received insulin injections during the lookback period. However, the Medication Administration Record (MAR) did not show any insulin administration for the month. The MDS Coordinator stated she had recorded an insulin injection because the resident was receiving Ozempic, not realizing that Ozempic is not an insulin but a GLP-1 receptor agonist. The facility did not have a specific policy for MDS assessments and relied on the RAI Manual for guidance.