Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for two residents. For one resident, the quarterly MDS indicated the resident was cognitively intact, had a diagnosis of diabetes, and received seven days of insulin injections. However, review of the medication administration record (MAR) did not show any insulin injections administered during the observation period. Further investigation revealed that the resident was prescribed Metformin, an oral diabetes medication, and Victoza, a non-insulin injectable medication. Both the registered nurse and the Director of Nursing confirmed that Victoza is not an insulin and should not have been recorded as such on the MDS. For another resident, the quarterly MDS documented an active diagnosis of non-Alzheimer's dementia. Upon review of the resident's medical record, there was no documentation to support a diagnosis of non-Alzheimer's dementia. The Director of Nursing confirmed that this was an error in the MDS coding, as the diagnosis was not present in the medical record. These inaccuracies in the MDS assessments were identified through interviews and record reviews.