Inaccurate MDS Assessment of Medication Administration
Penalty
Summary
The facility failed to ensure that a resident's Quarterly Minimum Data Set (MDS) assessment accurately reflected the medications administered during the required lookback period. Review of the electronic medication administration record (eMAR) showed that the resident received Lasix, a diuretic, and Trazodone, an antidepressant, during the assessment period. However, the corresponding MDS assessment did not indicate the use of either a diuretic or an antidepressant in the relevant sections, and instead marked 'none of the above.' Interviews with the Clinical Care Coordinator, Director of Nursing, and Administrator confirmed that the MDS was not completed accurately as required, and the medication use should have been documented in the assessment.