Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the health and functional status of three residents. For one resident, the MDS assessment did not document a history of fall and surgery, despite the resident being admitted with a hip fracture following a fall and subsequent surgery. The MDS nurse acknowledged that the fall and surgery were not coded in the assessment, and both the Director of Nursing (DON) and the Administrator confirmed that their expectation was for MDS assessments to be completed accurately, with staff responsible for ensuring the accuracy of the information. Another resident's quarterly MDS assessment inaccurately indicated the use of restraints and alarms, although observations and staff interviews confirmed that the resident did not use any restraints or alarms. The MDS nurse and other staff members recognized this as an error, and the DON emphasized the importance of accurate documentation, as it reflects the resident's condition and ensures appropriate care is provided. The facility's job description for the MDS Coordinator and professional references reviewed also highlighted the requirement for assessments to accurately reflect the resident's status in accordance with state and federal guidelines. A third resident's MDS assessment failed to document the use of a bed sensor alarm, even though the alarm was observed in use and was included in the resident's care plan and provider's orders. The MDS nurse confirmed that the assessment did not accurately reflect the resident's current care needs and acknowledged the responsibility to review care plans and provider orders during assessments. The DON reiterated the expectation that the MDS should reflect the resident's current care needs and that assessments should be conducted in a timely and accurate manner.