Inaccurate Resident Assessments Documented in Clinical Records
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status for two of twenty records reviewed. For one resident with diagnoses including COPD, hyperlipidemia, and dysphagia, the clinical record showed facility-acquired pressure ulcers, two falls (one with injury), and receipt of hospice services. However, the resident's quarterly MDS assessment was inaccurately coded, indicating a significant weight gain (which was not present), no hospice care, no falls since the previous assessment, and community-acquired rather than facility-acquired pressure ulcers. These inaccuracies were confirmed by the MDS Coordinator during an interview. Another resident with multiple diagnoses, including dehiscence of a surgical wound, COPD, diabetes with polyneuropathy, artificial hip joint, history of falling, chronic kidney disease, and muscle weakness, was documented in the clinical record as having been discharged home to the community. However, the discharge MDS incorrectly coded the discharge as a planned discharge to a short-term general hospital. The DON confirmed during an interview that the discharge MDS was coded incorrectly and should have reflected a discharge to the community.