Failure to Accurately Complete and Document MDS Assessments
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for two residents. For one resident, the facility did not complete a Discharge MDS assessment upon the resident's discharge home with a family member, as confirmed by both the MDS Coordinator and the Administrator, who acknowledged the assessment was missed due to oversight. Review of the resident's records showed no Discharge MDS was present, despite the requirement to complete one at the time of discharge. For another resident with a history of non-Alzheimer's dementia and neurogenic bladder requiring a suprapubic catheter, the facility did not accurately document the administration of an intravenous antibiotic (ertapenem) in the MDS assessment. The resident received the antibiotic as ordered during the 7-day look back period, as evidenced by the Medication Administration Record (MAR), but the MDS did not reflect this. This omission was confirmed during interviews with the MDS Nurse and Regional MDS Nurse, who agreed the assessment should have indicated antibiotic use during the specified period.