Inaccurate MDS Assessment Due to Omission of Opioid Administration
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment was completed accurately for a resident admitted with diagnoses including fibromyalgia and rhabdomyolysis. The resident had a physician's order for Percocet to be administered as needed for severe pain, and the Medication Administration Record showed that the resident received Percocet on four separate days during the observation period. However, the MDS admission assessment incorrectly indicated that the resident did not receive any opioids during the look-back period. The MDS Nurse confirmed during interviews and record reviews that the assessment should have been coded to reflect opioid administration but was not. Further review of the facility's policies and procedures revealed requirements for comprehensive, accurate, and standardized assessments, as well as for ensuring that the information captured on the assessment reflects the resident's status during the observation period. The MDS Nurse acknowledged that the facility did not follow these policies. Additionally, the CMS RAI manual was referenced, which outlines the need to review medical records for medication administration during the look-back period. The failure to accurately document opioid administration resulted in an inaccurate assessment of the resident's care and support needs.