Inaccurate MDS Assessments for Falls, Antipsychotic Use, and Discharge Status
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three of fifteen sampled residents, as required by their policy and the Resident Assessment Instrument (RAI) User Manual. For one resident, the admission MDS did not reflect a fall with minor injury that occurred the day before the assessment reference date, despite documentation in the event report and confirmation by the MDS Coordinator and Clinical Reimbursement Consultant that the fall should have been recorded. Another resident with a history of psychiatric diagnoses, including paranoid personality disorder, major depressive disorder, and schizophrenia, received antipsychotic medication (Seroquel) on multiple occasions as documented in the Medication Administration History. However, the quarterly MDS assessments for this resident incorrectly indicated that no antipsychotic medications were received, which was acknowledged as an oversight by the MDS Coordinator and confirmed by the Clinical Reimbursement Consultant. A third resident, admitted with a cervical vertebra fracture, was discharged home with home health services according to physician orders, progress notes, and the face sheet. Despite this, the discharge MDS inaccurately documented the discharge status as a transfer to a short-term general hospital. The MDS Coordinator and Director of Nursing both confirmed the error, stating the MDS should have reflected a discharge to home with home health services.