Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for three residents, as required by the Resident Assessment Instrument (RAI) User's Manual. For one resident, the quarterly MDS assessment did not indicate the administration of anticonvulsant medication, despite physician's orders and the Medication Administration Record (MAR) confirming that the resident received Divalproex during the seven-day look-back period. This discrepancy was confirmed by the Quality Assurance and Performance Improvement Registered Nurse. Another resident's significant change in status MDS assessment was inaccurately coded regarding cognitive status. Although the resident was sometimes understood, the assessment was marked as if the resident was rarely/never understood, resulting in the Brief Interview for Mental Status (BIMS) not being attempted, contrary to manual instructions. Additionally, a third resident's significant change MDS assessment failed to indicate the administration of antibiotics, antiplatelet medications, and the presence of IV access, despite physician's orders and the MAR confirming these treatments occurred during the assessment period. These inaccuracies were confirmed through staff interviews.