Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for four out of thirteen residents reviewed. For one resident, the Medication Administration Record (MAR) showed that an opioid was administered during the MDS look-back period, but this was not documented in Section N of the MDS. The MDS Coordinator acknowledged that the opioid use should have been marked, indicating inaccurate MDS coding. Another resident's quarterly MDS indicated the presence of delusion in Section E, but there was no supporting documentation in the Electronic Health Record (EHR) for this behavior during the observation period. The MDS Coordinator was unable to find any evidence to support the coding of delusion and confirmed it should not have been coded. The Director of Nursing stated that MDS assessments are expected to be coded accurately. For a third resident, the MDS indicated that the resident was rarely or never understood and did not complete the activity preferences interview with the resident's family or significant other, as required when the resident cannot communicate. The MDS Coordinator admitted that no attempt was made to contact the family or significant other. In the fourth case, the MDS showed that a resident received an insulin injection during the observation period, but there was no physician's order for insulin, and the MDS Coordinator confirmed that insulin should not have been coded. The Director of Nursing reiterated the expectation for accurate MDS completion.