Inaccurate MDS Assessments for Diagnoses, Falls, and Medication Administration
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) 3.0 assessments for three residents, resulting in incomplete or incorrect documentation of diagnoses, events, and medication administration. For one resident with a history of bipolar disorder and depression, the MDS assessment did not document these psychiatric diagnoses, despite active physician orders and ongoing administration of Quetiapine Fumarate and Sertraline HCl for these conditions. Both the DON and MDS Coordinator confirmed that these diagnoses should have been included in the MDS to accurately reflect the resident's care needs. Another resident who experienced a fall resulting in a right hip fracture and subsequent hospital transfer had an MDS assessment that failed to indicate the occurrence of a fall, with Section J1800 incorrectly coded as 'No.' The MDS Coordinator acknowledged this error. Additionally, a third resident receiving Hydroxyzine HCl for anxiety was not documented as having received an antianxiety medication in the MDS assessment, despite clear physician orders and medication administration records. The MDS Coordinator confirmed the omission and the need for accurate MDS documentation to convey resident needs.