Inaccurate Resident Assessments and MDS Coding Errors
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the status of three residents. For one resident with anxiety disorder and dementia, a soft padded helmet was ordered for injury prevention at the family's and hospice's request. Although the helmet could be removed by the resident at will and did not meet the definition of a restraint, it was incorrectly coded as a restraint on multiple Minimum Data Set (MDS) assessments. Staff interviews and documentation confirmed that the helmet was not restrictive, and the coding was acknowledged as erroneous by facility leadership. Another resident with depressive disorder and hypertension had an active order for zolpidem, a hypnotic medication, but this was not coded in the medication section of both the annual and quarterly MDS assessments. Additionally, a third resident with dementia and schizoaffective disorder was receiving haloperidol, an antipsychotic medication, as documented in the Medication Administration Record, but the corresponding MDS assessment incorrectly indicated that no antipsychotic medications had been administered. These inaccuracies were confirmed by the Director of Nursing and the Nursing Home Administrator.