Inaccurate Resident Assessments Documented in MDS
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the status of three residents. For one resident with hemiplegia and hemiparesis following a stroke, the Medicare 5 Day MDS was coded as having no impairment in upper extremities, despite clinical records indicating otherwise. The DON confirmed this MDS coding was inaccurate. Another resident with bipolar disorder, depression, opioid dependence, and a healing femur fracture was inaccurately coded in several areas: the MDS indicated two or more falls with no injury, although a skin tear was documented after one fall; a gradual dose reduction of antipsychotic medication was recorded without supporting documentation; and a significant change MDS failed to note a recent femur fracture from a fall, as well as omitted physician documentation that a gradual dose reduction was clinically contraindicated, despite a psychiatric consult stating so. The DON confirmed these MDS assessments were also inaccurate. A third resident, diagnosed with type 2 diabetes mellitus and cerebral palsy, was incorrectly coded as receiving tube feedings on the quarterly MDS, although both the resident and clinical records confirmed that tube feedings were never provided and no physician orders existed for such treatment. The DON acknowledged this MDS assessment was incorrect. These findings were based on clinical record reviews and interviews with residents and staff.