Inaccurate Resident Assessments Identified
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' clinical status for three of nineteen residents reviewed. For one resident with diabetes mellitus and neuropathy, the Minimum Data Set (MDS) assessment did not indicate that the resident received an anticonvulsant medication, despite the Medication Administration Record (MAR) showing administration of gabapentin during the assessment period. For another resident with dementia and anxiety disorder, the MDS was coded to show receipt of a hypnotic medication, but the MAR did not document administration of such medication during the same period. Additionally, a third resident with type 2 diabetes mellitus and edema was found to have an unstageable pressure injury to the right heel that originated after admission. However, two MDS assessments incorrectly indicated that the pressure injury was present upon admission. These discrepancies were identified through clinical record reviews and staff interviews, demonstrating a failure to ensure the accuracy of resident assessments as required.