Inaccurate MDS Assessment of Insulin Administration
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected a resident's medication usage. Specifically, a review of one resident's medical record showed that the MDS assessment documented insulin injections being administered on all seven days of the assessment period. However, there was no documentation in the medical record to support that the resident had a diagnosis of diabetes, any current or past orders for insulin, or any evidence that injections were given during the look-back period. The MDS nurse reported using the Medication Administration Record (MAR) to complete Section N Medications but was unable to provide supporting documentation for the recorded insulin administration. Upon review, the nurse acknowledged the error in the MDS assessment.