Inaccurate Resident Assessments Documented in Multiple Cases
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' current status for three out of thirteen residents reviewed. For one resident with multiple diagnoses including depression, anxiety, intellectual disabilities, PTSD, cerebral palsy, and encephalopathy, the Minimum Data Set (MDS) assessment incorrectly indicated that the resident was still receiving an anticoagulant medication, even though it had been discontinued. The Director of Nursing (DON) confirmed that the MDS was inaccurate and the care plan was not updated to reflect the medication change. Another resident, who was at risk for malnutrition and had experienced significant weight loss, had an MDS assessment that failed to accurately document the weight loss, marking it as "No or unknown" despite clear evidence of an 11% loss in less than a month. A third resident with dementia, anxiety disorder, and delusional disorder had MDS assessments that inaccurately recorded the use of antipsychotic, antianxiety, and anticonvulsant medications, either omitting a documented dose reduction or indicating use of medications not actually administered. In each case, the DON acknowledged the MDS coding errors during interviews.