Inaccurate Resident Assessments Documented in MDS
Penalty
Summary
Facility staff failed to accurately complete assessments for two residents, resulting in Minimum Data Set (MDS) documentation that did not reflect the residents' true clinical status. For one resident with Alzheimer's disease, the MDS assessments indicated no impairment to the upper or lower extremities, despite multiple staff interviews and direct observation confirming the resident had significant bilateral lower extremity impairment, was dependent on staff for transfers, and required a Hoyer lift. Staff also reported the resident had limited range of motion in the lower extremities and had been unable to stand for an extended period, contradicting the MDS coding. In another case, the MDS for a resident with heart disease, diabetes, and lung disease was coded to indicate use of an invasive mechanical ventilator or respirator within the assessment period. However, observation and staff interviews confirmed the resident was not on a ventilator, and the room was not set up for such equipment. The Assistant Director of Nursing confirmed the MDS was coded in error and that the resident had not required ventilator support while at the facility.