Inaccurate MDS Assessments for Medication and Dialysis
Penalty
Summary
The facility failed to ensure accurate completion of resident assessments for two out of ten residents reviewed for the Minimum Data Set (MDS). For one resident, the quarterly MDS inaccurately indicated the use of insulin injections and orders for insulin in Section N, despite physician orders and the Medication Administration Record (MAR) showing that the resident was neither prescribed nor administered insulin during the look-back period. The MDS Coordinator confirmed during a joint record review that the resident should not have been marked for insulin use, and the Director of Nursing stated that the MDS was expected to be completed accurately. For another resident, the quarterly MDS failed to indicate that the resident was receiving dialysis in Section O, even though physician orders and the care plan documented regular dialysis treatments for renal failure. The MDS Coordinator acknowledged that the MDS should have reflected the resident's dialysis treatments. These inaccuracies were identified through interviews and record reviews, demonstrating that the facility did not ensure the MDS assessments were completed in accordance with the requirements outlined in the RAI Manual.