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 incorrect data being transmitted to CMS. For one resident with diagnoses including paranoid schizophrenia and psychosis, the MDS did not reflect the administration of risperidone, an anti-psychotic medication, despite physician orders and documentation indicating its use. The MDS nurse confirmed that the anti-psychotic drug section was not properly marked, which was inconsistent with the resident's medication records. Another resident, diagnosed with congestive heart failure, anemia, and psychosis, experienced significant weight loss over a one-month period, as documented in the weights and vitals summary. However, the MDS assessment failed to code this weight loss under the appropriate section, despite clear evidence from the resident's records. The MDS nurse acknowledged the error, noting that the assessment should have indicated the resident was on a physician-prescribed weight-loss regimen due to the documented weight loss. A third resident, with diagnoses including hypertension, schizoaffective disorder, and atrial fibrillation, was prescribed Dabigatran Etexilate Mesylate, an anti-coagulant, as indicated in the order summary and care plan. The MDS assessment, however, did not document the use of this anti-coagulant. The MDS nurse confirmed that the medication should have been coded accordingly. Facility policies reviewed indicated that staff completing any portion of the MDS are required to certify the accuracy of the information provided.