Inaccurate MDS Assessments for Medications, Dental Status, and Restorative Care
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for multiple residents, resulting in inaccurate documentation of clinical care and services provided. For one resident with adult onset diabetes mellitus, the quarterly MDS assessment was coded to indicate receipt of an insulin injection during the assessment period, but the medication administration record (MAR) showed no evidence of insulin being administered. Instead, the resident received Trulicity, a GLP-1 receptor agonist, which is not classified as insulin. Similarly, another resident was coded as having received an insulin injection, but the MAR indicated only an order for Wegovy, also a GLP-1 receptor agonist, and no actual injections were administered during the assessment period. The DON confirmed that both medications were incorrectly coded as insulin on the MDS due to a misunderstanding by the MDS nurses. Another resident's admission MDS assessment inaccurately documented oral/dental status. Despite the resident and her daughter reporting concerns about a broken lower denture during a care conference, and the resident being observed as edentulous on the bottom with a broken lower denture, the MDS was marked as indicating no broken or loosely fitting dentures. The DON verified that this section of the MDS was marked inaccurately. Additionally, a fourth resident's annual MDS assessment indicated participation in restorative nursing programs for passive and active range of motion and bed mobility, with documentation of minutes provided. However, a review of the resident's medical record and physician's orders revealed no evidence of restorative nursing program orders or documentation of services provided in the past year. The DON confirmed the absence of such documentation and acknowledged the MDS was marked inaccurately for these services.