Inaccurate MDS Assessments for Restraint and Insulin Administration
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents. For one resident, the MDS inaccurately indicated the use of a physical restraint, specifically a bed rail, when in fact the resident had never had a restraint and the bed rails in use did not restrict movement. This was confirmed through interviews and direct observation, as well as a review of the resident's medical record and the facility's Matrix form. For another resident, the MDS assessments incorrectly documented the administration of insulin during two separate assessment periods. Review of the medical record showed that the resident had not received insulin during those times. The MDS Coordinator stated that the error occurred because she had mistakenly recorded the use of Victoza, a non-insulin injectable diabetes medication, as insulin. Upon review, the MDS Coordinator acknowledged that Victoza is not an insulin and that the MDS entries were inaccurate.