Inaccurate MDS Documentation for Dialysis and Oxygen Therapy
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the care and treatments provided to two residents. For one resident with end stage renal disease, high blood pressure, and diabetes, the MDS did not indicate that dialysis was performed, despite physician orders and the care plan confirming regularly scheduled dialysis sessions. This omission was confirmed by the Registered Nurse Assessment Coordinator (RNAC) during an interview. For another resident with diabetes, high blood pressure, and dependence on supplemental oxygen, the MDS did not indicate that oxygen therapy was being provided, even though physician orders and the care plan documented continuous oxygen use via nasal cannula. The RNAC also confirmed this discrepancy during an interview. These findings were based on a review of facility policy, the RAI User's Manual, clinical records, and staff interviews.