Inaccurate MDS Assessments for Medications, Smoking, and Diet
Penalty
Summary
The facility failed to complete accurate Comprehensive Minimum Data Set (MDS) assessments for three residents, resulting in deficiencies in care planning and delivery. For one resident with vascular dementia and congestive heart failure, the facility did not accurately code the use of diuretic medication on the MDS, despite physician orders and medication administration records confirming the resident received a diuretic during the assessment period. The MDS nurse acknowledged that the medication should have been coded but was not. Another resident with chronic heart failure, morbid obesity, diabetes, and hypertension was incorrectly coded on the MDS as receiving anticoagulant medication, when in fact only antiplatelet medications (aspirin and clopidogrel) were ordered and administered. The MDS nurse admitted to misclassifying the medications, having assumed that clopidogrel was an anticoagulant, and this error was also reflected in the resident's care plan. Additionally, the facility failed to accurately code tobacco use and therapeutic diet status for two residents. One resident, identified as a smoker and care planned for smoking, was incorrectly coded as not using tobacco on the MDS, despite direct observation and interview confirming ongoing smoking. Another resident, with end stage renal failure and on dialysis, was not coded as receiving a therapeutic diet on two consecutive MDS assessments, even though physician orders indicated a prescribed therapeutic diet during the relevant periods. The MDS nurse confirmed these omissions.