Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected the status of two residents. For one resident with diagnoses including bipolar disorder, traumatic brain injury, mood disorder, depression, and anxiety, the quarterly MDS indicated no use of antipsychotic medications. However, the resident had a physician's order for aripiprazole, an antipsychotic, and received it daily during the MDS lookback period. The Case Mix Director stated she had marked antipsychotic use originally but later changed all MDS assessments to show no antipsychotic use, believing it was inaccurate, and did not see the medication in the resident's list at the time of assessment. For another resident with chronic kidney disease, the quarterly MDS indicated the resident was receiving dialysis, but there was no order or evidence in the medical record that dialysis treatment was provided. The Case Mix Coordinator acknowledged that the resident had never been on dialysis and that the entry was made in error. The Director of Nursing confirmed that each MDS was reviewed for accuracy by the Case Mix Director prior to submission and should reflect an accurate assessment of each resident.