Inaccurate and Incomplete MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy and completeness of Minimum Data Set (MDS) assessments for two residents. For one resident admitted with a left hip fracture, the MDS assessment indicated that she received insulin and a diuretic during the assessment period, but a review of the physician's orders and Medication Administration Record (MAR) confirmed that she had not been prescribed or administered either medication during that time. For another resident, the required discharge MDS was not completed following the resident's discharge, as verified through medical record review. These deficiencies were confirmed during an interview and record review with the MDS Coordinator, who acknowledged the inaccuracies and omissions in the MDS documentation.