Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents. For one resident, the MDS indicated that insulin injections were administered for seven days during the look-back period; however, a review of the clinical record did not show any physician order for insulin injections. This discrepancy suggests that the MDS assessment did not accurately represent the resident's actual care and treatment as documented in the clinical record. For another resident, the quarterly MDS assessment failed to indicate that the resident was receiving hospice care, despite a physician order for hospice services due to a terminal diagnosis of neurocognitive disorder with Lewy bodies. The MDS section for hospice care was coded as 'no,' which did not match the resident's documented status and physician orders. These findings were confirmed by the Registered Nurse Assessment Coordinator during an interview.