Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the clinical status and care needs of five residents. For one resident, the MDS incorrectly documented multiple falls, including injury and major injury falls, when the incident reports only supported one fall and one non-fall injury. Additionally, the MDS did not accurately reflect the resident's active diagnosis of depression, despite physician documentation and ongoing antidepressant therapy. Another resident's MDS failed to include an active diagnosis of depression, even though the care plan and medication administration records indicated daily antidepressant use for depression. For a third resident, the MDS did not capture behavioral issues or cognitive changes, despite progress notes and assessments indicating confusion, hallucinations, and serious mental illness indicators. Staff interviews confirmed a lack of awareness and failure to update the MDS in response to these documented changes. Two additional residents had MDS assessments that did not reflect significant behavioral incidents or cognitive changes. One resident had documented episodes of attempted elopement, verbal and physical aggression, and medication non-compliance, none of which were captured in the MDS. Another resident with intermittent confusion, delusional thought content, and a diagnosis of moderate dementia with psychotic disturbance was not accurately represented in the MDS regarding behaviors and cognition. Staff interviews revealed that updates to the MDS were not made despite clear documentation of these issues in the residents' records.