Inaccurate MDS Assessment Due to POLST Discrepancy
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident with a medically complex condition. The resident's MDS assessment, specifically section S which documents Physician Orders for Life-Sustaining Treatment (POLST), indicated that the resident had chosen to receive full treatment, including resuscitation and a trial period of artificial nutrition via feeding tube. However, a review of the resident's signed POLST form revealed that the resident had actually chosen Do Not Resuscitate (DNR), selective treatment, and no artificial means of nutrition, including feeding tubes. This discrepancy was confirmed during interviews with the MDS coordinator and the Director of Nursing (DON), both of whom acknowledged that the MDS assessment did not accurately reflect the resident's documented wishes as indicated on the POLST form. Further investigation revealed that the facility did not have a policy or procedure in place regarding the completion of MDS assessments. The DON confirmed that the information in section S of the MDS should be transcribed directly from the signed POLST form, and that any mismatch would render the MDS assessment inaccurate. The lack of an accurate MDS assessment could result in care and treatment that does not align with the resident's documented preferences. The findings were supported by a review of relevant professional guidance, which emphasized the importance of accurate documentation for MDS accuracy.