Inaccurate MDS Assessments for Medications, Oral Status, and Hospice Care
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents, resulting in deficiencies related to oral/dental status, medication use, and hospice care. For one resident, the quarterly MDS indicated the use of an antidepressant medication during the seven-day look-back period, but the Medication Administration Record (MAR) showed the antidepressant had been discontinued and was last administered prior to the assessment period. The MDS Registered Nurse acknowledged that Section N was not coded accurately based on the resident's actual medication administration. Another resident's admission MDS failed to indicate that the individual was edentulous, despite both a nutritional risk assessment and direct observation confirming the absence of natural teeth. The MDS nurse stated that Section L should have been coded to reflect the resident's edentulous status, as supported by documentation and resident interview. The Director of Nursing confirmed the expectation that MDS assessments be completed accurately. A third resident's quarterly MDS was marked to indicate receipt of hospice care, but a review of physician orders and the electronic health record did not show any documentation of hospice services. Staff interviews confirmed that the resident was not under a hospice program but was instead receiving comfort care. The MDS nurse acknowledged that hospice care should not have been marked in the assessment. The Director of Nursing reiterated the facility's expectation for accurate MDS coding.