Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, resulting in documentation errors regarding their clinical status and care needs. For one resident with Parkinson’s disease and dementia, the Significant Change MDS incorrectly recorded the number and type of falls, documenting only one non-injury fall when records showed two falls, one of which resulted in a minor injury. Observations confirmed the resident’s high level of dependency and fall risk, and staff interviews acknowledged the MDS inaccuracy. The facility’s own documentation and staff statements confirmed that the MDS did not accurately reflect the resident’s fall history as required by the Resident Assessment Instrument (RAI) manual. For another resident with dementia, the Quarterly MDS inaccurately indicated that the resident received an anticoagulant during the assessment period, when in fact the resident was only receiving an antiplatelet medication (aspirin). The resident’s cognitive status was also documented inconsistently between assessments. Staff interviews confirmed the MDS error, and facility policy required accurate and timely completion of the MDS. These inaccuracies in the MDS assessments placed the residents at risk for impaired care due to unidentified or misidentified care needs.