Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the clinical status and care needs of multiple residents. For one resident, the annual MDS indicated no dental concerns, despite the resident reporting broken teeth and documentation showing decayed and broken teeth requiring dental intervention. Another resident's significant change MDS failed to indicate the use of diuretic and antipsychotic medications, even though medication records confirmed daily administration of both. A third resident's MDS did not reflect a serious mental illness diagnosis, despite behavioral health documentation supporting the presence of such a condition and the need for specialized services. Additional deficiencies included a resident with a colostomy being incorrectly coded as occasionally incontinent of bowel on the MDS, rather than indicating the presence of an ostomy. Another resident's discharge MDS was inaccurately coded, failing to reflect that the resident left the facility against medical advice. In each case, staff interviews confirmed the inaccuracies in the MDS coding, and the need for modifications to ensure accurate assessments as required by facility policy and regulatory standards.