Inaccurate MDS Assessments and Documentation Errors
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) 3.0 assessments were completed accurately for five residents. In one case, a resident was incorrectly documented as having a Stage III pressure ulcer present on admission, despite medical records and staff interviews confirming that no such ulcer was present at that time. Another resident was inaccurately assessed as being dependent on staff for activities of daily living, when nursing progress notes indicated the resident was independent or only required supervision for most tasks. A third resident's MDS assessment underreported the number of insulin injections received, stating only one injection in the look-back period when medication records showed daily administration. For another resident, the MDS inaccurately reflected severe cognitive impairment and enteral feeding compliance, despite multiple staff interviews and observations revealing the resident refused enteral feedings, consumed nutrition orally against orders, and was not receiving the documented amounts via the feeding tube. The staff responsible for the assessment did not document refusals or update the MDS to reflect the resident's actual intake and behavior. Additionally, a resident with a documented pressure wound and high risk for pressure sores was not accurately represented in the MDS, which failed to note the presence of the wound or the interventions in place. Staff interviews confirmed the inaccuracies in the assessments and a lack of awareness among clinical leadership regarding the residents' actual conditions and care needs. These findings demonstrate a pattern of incomplete or incorrect MDS documentation based on inconsistent or unverified information from the medical record and staff observations.