Inaccurate MDS Assessments Documented for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately recorded for four residents. In one case, a resident's MDS indicated the use of a limb restraint, but both the resident and family denied any restraint use, and staff confirmed the facility was restraint-free. Another resident's MDS failed to document impaired range of motion (ROM) in the right lower extremity following hip surgery, despite therapy records indicating impairment. Additionally, the completion date for this resident's MDS was inaccurately recorded, as some sections were finalized after the documented completion date. A third resident's discharge MDS incorrectly stated the resident was discharged to an acute hospital, when in fact the resident was discharged home. In another instance, a resident with a history of neck fractures and documented bilateral upper extremity ROM impairment in therapy evaluations was inaccurately recorded in the MDS as having no impairment. Staff interviews revealed that delays in receiving therapy data contributed to these inaccuracies, and staff responsible for MDS completion acknowledged the errors.