Inaccurate MDS Assessment Documentation for Discharge
Penalty
Summary
The facility failed to accurately document a discharge Minimum Data Set (MDS) assessment for a resident who was admitted as a hospice respite patient. Record review showed that the resident experienced two falls, as documented in progress notes, and was assessed for injury on both occasions. However, the discharge MDS assessment incorrectly indicated that the resident had not experienced any falls since admission, which was later confirmed as an error by the MDS Coordinator. Additionally, the resident had orders for two pain medications, Tylenol and Morphine, both prescribed on an as-needed basis. Review of the Medication Administration Record (MAR) revealed no documentation that either medication was administered. Despite this, the discharge MDS assessment inaccurately documented that the resident was on a scheduled pain medication regimen. The MDS Coordinator confirmed that this was also a documentation error.