Inaccurate MDS Assessments for Discharge Status and Restraint Use
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for two residents. For one resident with diagnoses including dementia, atrial fibrillation, and heart failure, the medical record and care plan indicated a planned discharge to home under the care of her daughter. However, the discharge MDS assessment inaccurately documented the discharge location as an acute care hospital. The Director of Nursing (DON) confirmed the discrepancy, acknowledging the MDS assessment did not reflect the actual discharge destination. For another resident with congestive heart failure, diabetes mellitus, and depression, the quarterly MDS assessment indicated the use of a trunk restraint less than daily. However, review of the care plan and direct observations revealed no evidence of trunk restraint use, and the resident confirmed he had not used such a device at the facility. The DON also confirmed the inaccuracy of the MDS assessment regarding restraint use. These findings demonstrate failures in accurately assessing and documenting resident status as required by the MDS 3.0 RAI Manual.