Inaccurate and Untimely MDS Assessments Identified
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for two residents, as required by the Resident Assessment Instrument (RAI) Manual. For one resident with a history of Type 2 diabetes mellitus, diabetic neuropathy, major depressive disorder, and seizure disorder, the clinical records, medication administration records, and care plans all indicated an active diagnosis of seizure disorder and ongoing treatment with Divalproex. However, the quarterly MDS assessment did not reflect the seizure disorder as a current diagnosis, despite multiple sources confirming its presence and treatment. For another resident with nonrheumatic aortic stenosis and cellulitis of the left lower limb, the quarterly MDS assessment was not completed within the required 14-day timeframe following the assessment reference date. The MDS was finalized 15 days after the reference date, exceeding the regulatory limit. Interviews with facility staff confirmed these deficiencies, and the facility was unable to provide documentation to support the accuracy of the MDS coding for these residents.