Inaccurate MDS Assessments for Discharge Status, Diagnosis, and Medication Use
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents, resulting in incorrect documentation of discharge status, active diagnoses, and medication use. For one resident, the discharge MDS inaccurately indicated a discharge to the hospital, despite nursing progress notes and staff interviews confirming the resident was discharged home. Staff acknowledged the error and confirmed that the MDS should have reflected a discharge to home/community. Another resident's admission MDS did not document a diagnosis of dementia, even though the resident's face sheet and physician progress notes during the look-back period confirmed the diagnosis and corresponding medication use. Staff confirmed that dementia should have been marked on the MDS. Additionally, a third resident's admission MDS failed to indicate the use of antianxiety medication during the look-back period, despite the Medication Administration Record (MAR) showing administration of such medication on multiple dates. Staff interviews and joint record reviews confirmed that the resident received antianxiety medication and that this should have been documented in the MDS. These inaccuracies were identified through interviews, record reviews, and joint reviews with staff, who acknowledged the discrepancies and the expectation for MDS assessments to be completed accurately according to the RAI MDS Manual.