Inaccurate Resident Assessments Documented in Clinical Records
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' current status for two individuals. For one resident with chronic kidney disease and anxiety disorder, the Quarterly Minimum Data Set (MDS) assessment incorrectly indicated a fall with major injury during the look-back period. Clinical record review showed that this resident experienced a fall with no injuries and another with only a minor injury, contradicting the MDS documentation. For another resident with similar diagnoses, the Quarterly MDS assessment inaccurately reported the use of an antidepressant medication during the look-back period. However, review of current physician orders confirmed that the resident was not receiving any antidepressant medications at that time, and the previously prescribed antidepressant had been discontinued several months prior. These inaccuracies were identified through clinical record review and staff interviews.