Inaccurate MDS Assessments for Two Residents
Penalty
Summary
Facility staff failed to ensure accurate Minimum Data Set (MDS) assessments for two residents. For one resident with multiple diagnoses including mild cognitive impairment, cerebral infarction, and right-side hemiparesis, staff did not code the use of a right-hand splint and right elbow extension brace on the MDS assessment, despite provider orders, care plan documentation, and treatment administration records confirming the use of these devices for contracture management. The resident was observed by the surveyor wearing the splint, and the care plan and orders clearly indicated the need for these interventions, but the MDS did not reflect this information. For another resident with diagnoses such as cerebral infarction, metabolic encephalopathy, and moderate cognitive impairment, staff incorrectly coded the MDS to indicate the use of anticoagulant medication during the assessment period. A review of the clinical record did not show evidence that the resident received any anticoagulant medication in the relevant seven-day period. The MDS Coordinator confirmed the error after reviewing the record. No additional information regarding these concerns was provided to the survey team prior to the exit conference.