Inaccurate MDS Assessments for Discharge Disposition and Active Diagnoses
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, resulting in inaccurate documentation of their status and diagnoses. For one resident, the MDS assessment incorrectly indicated that the resident was discharged to a short-term general hospital, while multiple other records, including physician orders, nursing progress notes, and the discharge summary, all documented that the resident was actually discharged to another skilled nursing facility. The MDS nurse responsible for completing the assessment acknowledged that the wrong discharge disposition was selected in error, leading to an inaccurate medical record. For another resident, the MDS assessment did not include an active diagnosis of anxiety, despite the resident's history and physical, psychiatric progress notes, and care plan all documenting anxiety as a current condition. The resident was receiving Ativan for anxiety, and the care plan specifically addressed interventions for anxiety-related behaviors. The MDS nurse confirmed that anxiety should have been included as an active diagnosis in the MDS to ensure accurate documentation of the resident's medications and diagnoses. Facility policy requires that MDS assessments be completed accurately and reflect information consistent with progress notes, care plans, and resident observations. The deficiencies identified were due to staff errors in completing the MDS, resulting in discrepancies between the MDS and other clinical documentation for both residents.