Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two of twenty sampled residents. For one resident with a diagnosis of cerebral infarction, records showed she was admitted to hospice services, but her Quarterly MDS assessment did not indicate that she was receiving hospice care during the lookback period. Interviews with nursing staff confirmed that the resident had been on hospice since the previous year, and the omission was not identified or corrected in the MDS documentation. The process for verifying MDS accuracy was limited to staff reviewing their own sections, with no system in place to ensure overall accuracy, and the RN signature only indicated completion, not verification of accuracy. For another resident with a diagnosis of atherosclerotic heart disease, the Quarterly MDS assessment incorrectly coded the use of bed rails as a physical restraint. Facility staff, including an LPN, stated that bed rails were not considered restraints and were used to assist with mobility, and the coding of restraints on the MDS was an error. The administrator confirmed that MDS assessments are expected to accurately reflect residents' status, but the errors in both cases demonstrated a failure to ensure accurate assessment documentation.