Inaccurate MDS Assessment Documentation
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected a resident's current status. Clinical record review showed that a resident with diagnoses including diabetes mellitus, muscle weakness, a need for assistance with personal care, and major depressive disorder had physician orders for the application and monitoring of an electronic monitoring device on multiple occasions. However, review of the MDS assessments for this resident indicated that the use of the electronic monitoring device was not documented, despite ongoing physician orders. The Director of Nursing confirmed that the MDS assessments were inaccurate and did not reflect the resident's actual use of the device.