Inaccurate MDS Assessments for Swallowing Disorders, Pressure Ulcers, Dental Status, and Restraints
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for multiple residents, resulting in deficiencies in the areas of swallowing disorders, pressure ulcers, dental status, and physical restraints. For one resident with protein-calorie malnutrition and dysphagia, both a speech therapy evaluation and a nutrition evaluation documented clear signs and symptoms of a swallowing disorder, including loss of food from the mouth, coughing, and complaints of pain when swallowing. However, the quarterly MDS assessment did not reflect these symptoms, and the Regional MDS Consultant acknowledged this was an oversight due to the absence of a dedicated MDS Coordinator. Another resident with dementia and malnutrition was found to have two unstageable pressure ulcers that developed after admission, as documented by the Wound Care Practitioner. Despite this, the discharge MDS assessment incorrectly coded the ulcers as present on admission. Additionally, the same resident was observed to be edentulous and receiving pureed food, but both the admission and significant change MDS assessments failed to indicate the absence of natural teeth, despite a speech therapy evaluation noting edentulism upon admission. The MDS assessments were completed remotely, and the Regional MDS Consultant confirmed the errors after reviewing the medical records. Further inaccuracies were identified in the coding of physical restraints. One resident with intact cognition was documented in the MDS as using bed rails as a physical restraint, although the resident used the rails for mobility and repositioning, and the facility was restraint free. Another resident with moderately impaired cognition was incorrectly coded as using a chair restraint, despite being able to self-transfer and having no device preventing rising from the chair. These errors were confirmed by the Regional MDS Consultant and the Administrator, who both stated that the MDS assessments did not accurately reflect the residents' conditions or the use of restraints.