Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of two residents. For one resident, the quarterly MDS indicated no falls during the assessment period, despite documentation in the nursing progress notes that the resident had experienced a fall while attempting to retrieve clothing without staff assistance. The MDS Coordinator confirmed that the fall should have been captured in the MDS, but it was not, resulting in an inaccurate assessment. For another resident, the MDS was coded as a discharge to an acute care hospital, while health records and staff interviews confirmed that the resident was actually discharged home per physician orders. The MDS Coordinator acknowledged the error, stating that the MDS should have been coded as a discharge to home/community. These inaccuracies in the MDS assessments were identified through observation, interview, and record review, and were not in accordance with the facility's policy to follow the Resident Assessment Instrument guidelines.