Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents, resulting in discrepancies between the residents' actual conditions and what was documented. For one resident with a history of brain bleed and right side weakness, the MDS did not reflect participation in a Restorative Nursing Program (RNP) for range of motion, despite documentation and care plans indicating that such services were provided up to five times a week. Staff confirmed the inaccuracy upon review of the resident's record. Another resident with diagnoses of depression and anxiety was not accurately coded for anxiety on the MDS, even though psychiatric notes and preadmission screening documented both conditions and ongoing treatment needs. Additionally, a third resident with malnutrition and cancer was documented on the MDS as not having or being at risk for pressure ulcers, despite staff identifying and treating a pressure injury to the resident's tailbone. Staff acknowledged that the resident should have been coded as at risk for pressure ulcers and that the MDS required modification.