Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for three residents, as required by the Resident Assessment Instrument (RAI) Manual. For one resident with dementia, the quarterly MDS inaccurately documented pneumonia in the infection section, despite no evidence in the clinical record that the resident had pneumonia during the seven-day look-back period. The Registered Nurse Assessment Coordinator (RNAC) confirmed the inaccuracy. For another resident with Parkinson's Disease, the initial MDS indicated no impairment in range of motion, while occupational therapy documentation identified functional limitations and a goal to increase shoulder flexion. Observation revealed joint deformities in both hands, and the resident expressed a need for adaptive devices to eat. The RNAC and Director of Rehabilitation could not confirm the accuracy of the MDS coding and entered a correction during the survey. A third resident with moderate dementia and agitation had a quarterly MDS assessment that documented a gradual dose reduction of antipsychotic medication on a specific date. However, physician orders and nursing documentation showed the dose reduction occurred earlier, and the RNAC could not confirm the accuracy of the MDS coding. The Director of Nursing was also unable to provide documentation supporting the accuracy of the MDS for two of the residents. These findings were based on clinical record reviews, resident observations, and staff interviews.