Inaccurate MDS Assessments for Pain Management, Weight Loss, Hospice, Restraint, and Range of Motion
Penalty
Summary
Facility staff failed to ensure accurate completion of Minimum Data Set (MDS) assessments for multiple residents, resulting in several deficiencies. For one resident with multiple chronic conditions and severe cognitive impairment, staff did not accurately code the administration of PRN pain medication and failed to document a significant unplanned weight loss on the MDS, despite clear evidence in the medical record and medication administration records. Another resident receiving hospice care was not coded as such on the admission MDS, even though provider orders and the care plan indicated active hospice services. Additionally, a resident was incorrectly coded as using a limb restraint on a quarterly MDS assessment, although no restraint was observed and staff confirmed this was an error. In another case, two MDS assessments for a resident with severe cognitive impairment inaccurately documented functional limitations in lower extremity range of motion, which was inconsistent with other assessments and not supported by clinical findings. These deficiencies were identified through review of clinical records, medication administration records, and staff interviews. The surveyors found that the facility staff did not follow the Centers for Medicare & Medicaid Services Resident Assessment Instrument (RAI) guidelines for accurate MDS coding, leading to discrepancies between the residents' actual clinical status and what was documented in the MDS assessments.