Inaccurate MDS Assessments for Falls and Diagnoses
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents. For two residents, the MDS assessments did not accurately reflect their fall history or incidents of falls that occurred both prior to and after admission. Interviews with the residents confirmed they had experienced falls, and electronic health records documented these incidents. However, the admission MDS for both residents indicated no falls in the relevant timeframes, and the care area assessment (CAA) for falls was not triggered as a result. Staff interviews revealed that the MDS Coordinator did not review the residents' electronic health records when completing the assessments, leading to inaccurate documentation. For another resident, the quarterly MDS assessment listed a diagnosis of schizophrenia and did not indicate the use of antipsychotic medication. However, a review of the resident's diagnosis list showed that schizoaffective disorder - bipolar type had been added previously. Staff, including the MDS Coordinator and Resident Care Managers, were unable to provide documentation supporting this diagnosis and later determined it was likely a transcription error, with the wrong diagnosis code selected during data entry. These inaccuracies in the MDS assessments resulted from a lack of proper review and verification of resident records and diagnoses.