Inaccurate MDS Documentation for Medications, Restraints, and WanderGuard Alarms
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for seven residents, resulting in documentation errors related to medication administration, use of physical restraints, and the presence of WanderGuard alarms. Specifically, two residents had their non-insulin hypoglycemic medications (Ozempic, Metformin, and Trulicity) incorrectly coded as insulin, and these medications were not properly documented in the MDS. One resident was incorrectly coded as having a physical restraint due to the use of a bed positioning device, despite using it for mobility and independence rather than restraint. Four residents with physician orders for WanderGuard alarms were not accurately documented as having these devices in their MDS assessments. These inaccuracies were identified through observation, interviews, and record reviews. The MDS nurse responsible for completing the assessments acknowledged making errors in coding medications and WanderGuard alarms, attributing some mistakes to limited time and infrequent presence in the facility. Another administrative nurse reported that she expected the MDS to be accurate and that she reviewed and signed off on the assessments, but errors still occurred. The facility's policy requires that assessments accurately reflect the resident's status at the time of assessment, which was not met in these cases.