Inaccurate MDS Documentation of Insulin Administration
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident, specifically regarding the documentation of insulin administration. For a female resident with multiple diagnoses including Type 2 Diabetes Mellitus, COPD, hypertension, hypothyroidism, and anxiety disorder, the quarterly MDS assessment did not accurately record the number of days insulin injections were received in the seven days prior to the assessment. The MDS assessment indicated zero days of insulin administration, despite the Medication Administration Record (MAR) showing that insulin was administered on 25 of the 26 days preceding the assessment. The MDS Coordinator reported that she relies on administration reports to determine the number of days insulin was given and inputs this information into the MDS system. However, the discrepancy between the MAR and the MDS assessment resulted in inaccurate documentation. The facility's policy requires qualified staff to conduct accurate assessments and documentation, but this was not followed in this instance, leading to incomplete and inaccurate clinical records for the resident.