Inaccurate Resident Assessments and MDS Documentation
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current status of multiple residents, as evidenced by discrepancies found in the Minimum Data Set (MDS) documentation and care plans. For several residents with severe cognitive impairment and significant physical limitations, the use of side rails as restraints was not properly identified in their MDS assessments, despite staff and the Director of Nursing (DON) confirming that the side rails were used for safety and restraint purposes. Observations and interviews revealed that these residents were totally dependent on staff for activities of daily living (ADLs), had contractures or wore mittens, and could not use the side rails for mobility, yet the MDS did not reflect restraint use as required. In addition, the facility failed to accurately document other critical aspects of resident care. One resident's quarterly MDS inaccurately indicated that the resident was not receiving hospice care, despite documentation and physician certification confirming hospice enrollment and a prognosis of less than six months to live. Another resident's MDS failed to identify the presence of a current surgical wound, even though care plans, physician orders, and weekly skin assessments documented ongoing wound care for a post-surgical wound. In both cases, the DON acknowledged the inaccuracies and attributed them to the absence of a dedicated MDS nurse, with responsibilities temporarily handled by a company nurse who was unavailable at the time. The facility's own policy requires that all individuals completing any portion of the MDS assessment attest to the accuracy of the information provided. However, the lack of accurate and timely updates to the MDS assessments resulted in documentation that did not reflect the residents' true conditions or care needs. This deficiency was identified through a combination of record reviews, staff interviews, and direct observations, affecting multiple residents and potentially impacting the quality of care provided.