Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for six residents, resulting in multiple inaccuracies in resident records. For one resident with diagnoses including necrotizing fasciitis, septicemia, and diabetes mellitus, the MDS assessments repeatedly documented the presence of stage four pressure ulcers, despite the medical record and staff interviews confirming that the resident never had pressure ulcers during their admission. Both the MDS nurse and the Director of Nursing (DON) acknowledged that these MDS entries were inaccurate. Another resident with Alzheimer's disease and severe cognitive impairment was incorrectly coded on the MDS as using bedrails daily as physical restraints. Observations and record reviews showed that the resident's bed did not have bedrails, and there was no documentation of restraint use in the care plan or assessment records. Staff interviews confirmed that bedrails were not used for this resident and that the MDS coding was inaccurate. Additionally, three residents were inaccurately coded regarding their pneumococcal vaccination status. In two cases, the MDS indicated that the residents were up to date with the vaccine, but medical records showed that although consent was obtained, the vaccine had not been administered due to unavailability from the pharmacy. In another case, the MDS stated the vaccine was not offered, but documentation showed that consent had been signed. For another resident, an MDS assessment was completed after a hospital transfer, indicating a staff assessment of cognition, even though the resident did not return to the facility, making such an assessment impossible. Staff interviews confirmed these inaccuracies.