Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for four residents, as required by the Resident Assessment Instrument (RAI) User's Manual. For one resident, the MDS indicated that no antibiotic was received during the seven-day look-back period, despite the Medication Administration Record (MAR) showing administration of Metronidazole. Another resident's MDS assessment failed to record the use of an antianxiety medication, even though the MAR documented administration of Ativan during the relevant period. A third resident's admission MDS did not reflect the receipt of IV antibiotics, although the MAR confirmed administration of Ceftriaxone intravenously within the look-back period. Additionally, a fourth resident's annual MDS assessment did not indicate the administration of an anticonvulsant, an antidepressant, or an antianxiety medication, despite physician orders and the MAR confirming that Topiramate, Wellbutrin, and Buspirone were given during the seven-day look-back period. These discrepancies were confirmed through review of clinical records and staff interviews, including confirmation by the Nursing Home Administrator that the MDS assessments for these residents were coded inaccurately.