Inaccurate and Incomplete MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to accurately complete and code Minimum Data Set (MDS) assessments for three residents. One resident was admitted with a right femur fracture and underwent surgical repair, but the MDS admission assessment did not reflect her lower extremity impairment, despite documentation and interviews confirming the impairment. Another resident, admitted with a stroke resulting in right side weakness and contracture, had no assessment completed for activities of daily living on the MDS, even though therapy services and participation in daily activities were documented. A third resident was admitted under Hospice services for hypertensive heart disease with heart failure, but the MDS did not indicate receipt of Hospice services, despite multiple staff and documentation confirming the resident was on Hospice at admission. These deficiencies were identified through record reviews and staff and resident interviews, which revealed that the MDS assessments were either incomplete or inaccurately coded, failing to reflect the residents' actual care needs and conditions. Staff interviews acknowledged these errors as oversights and confirmed the importance of accurate MDS completion to represent resident care accurately.