Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) 3.0 assessments were completed accurately for two residents. For one resident, the MDS assessment indicated 'discharge return anticipated' after a hospital transfer, but the resident did not return to the facility. This error was confirmed by the MDS nurse during an interview. For the second resident, the initial nursing evaluation upon readmission did not address multiple vascular wounds to the left foot, and the five-day MDS assessment failed to document these wounds. Additionally, the resident's skin and wound evaluation noted an unstageable pressure ulcer on the right heel, but the assessment lacked wound measurements. Further review of the five-day MDS assessment for the second resident showed inconsistencies regarding cognitive status and assistance needs, and it did not address vascular wounds to the right toes. The MDS coordinator confirmed that the assessments did not reflect all existing wounds. These deficiencies were identified through medical record review and staff interviews during a complaint investigation.