Failure to Accurately Complete Resident Assessments
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status for two of the sampled residents. For one resident with a diagnosis of type 2 diabetes mellitus with hyperglycemia, physician orders and the Medication Administration Record (MAR) showed that the resident received daily insulin injections. However, the quarterly Minimum Data Set (MDS) assessment for this resident indicated that no injections of any type were received during the 7-day look-back period. This discrepancy was confirmed by the MDS/Care Plan Nurse, who acknowledged that the MDS assessment was inaccurate. For another resident with multiple diagnoses, including rheumatoid arthritis, sepsis, myelodysplastic syndrome, and acute pulmonary edema, the medical record indicated that the resident was on hospice and expired in the facility. Despite this, a review of the medical record revealed that a discharge MDS assessment had not been completed following the resident's death. The MDS/Care Plan Nurse confirmed that the discharge MDS assessment was missing and should have been completed.