Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the clinical status of three residents. For one resident with respiratory failure, tracheostomy, and continuous oxygen needs, the quarterly MDS assessment did not indicate that the resident was receiving continuous oxygen therapy, as-needed suctioning, or tracheostomy care, despite physician orders and treatment records confirming these interventions were provided. Another resident with schizophrenia had an annual MDS assessment that inaccurately documented the resident's PASARR status, indicating no need for a Level II PASARR, even though clinical records and a determination letter confirmed the requirement for specialized services due to a mental condition. A third resident, admitted with quadriplegia, was assessed on the admission MDS as having an indwelling urinary catheter, but direct observation revealed no catheter was present. In each case, the inaccuracies were confirmed by the Nursing Home Administrator during interviews. These findings demonstrate that the facility did not follow the required procedures for accurate MDS completion, including direct observation and proper documentation, as outlined in the RAI User's Manual and state regulations.