Inaccurate Resident Assessments Documented in Clinical Records
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' clinical status for four individuals. For one resident with anxiety disorder, epilepsy, and depression, the Minimum Data Set (MDS) assessments inaccurately documented the administration of antianxiety, anticonvulsant, and opioid medications, with discrepancies between the MDS and the Medication Administration Record (MAR). Another resident with anxiety, post-traumatic stress disorder, and hemophilia was incorrectly coded on the MDS as not having a related condition per the Preadmission Screening and Resident Review (PASRR), despite documentation from the state indicating otherwise. A third resident with chronic pain syndrome and a stage 4 pressure ulcer was not consistently coded on the MDS regarding the presence and admission status of the pressure ulcer, despite clinical records confirming its existence and that it was present upon admission. Additionally, this resident was receiving hospice services. For a fourth resident with schizoaffective disorder, bipolar disorder, and major depressive disorder, the MDS assessments failed to accurately reflect attempts at gradual dose reduction (GDR) for antipsychotic medications, even though clinical documentation and physician orders indicated that GDRs had been attempted and medication dosages had been adjusted. These inaccuracies were confirmed through clinical record reviews, MARs, and staff interviews, with the Director of Nursing acknowledging the errors in MDS coding. The deficiencies were identified during the survey process and were found to be in violation of state regulations regarding medical records and nursing services.