Inaccurate MDS Assessment for Restraint/Side Rail Use
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident, resulting in an incorrect indication that the resident had a restraint or side rail in use. The resident in question was a female with diagnoses of dementia and bipolar disorder, who was severely cognitively impaired and required supervision for mobility. Review of her care plans, physician's orders, and medication administration records showed no documentation or prescription for side rails or restraints. Observations confirmed that the resident did not have side rails or restraints on her bed. Interviews with facility staff, including the LVN, MDS Nurse, DON, and Administrator, consistently confirmed that the resident did not have side rails or restraints. The MDS Nurse acknowledged that the error was due to accidentally marking the side rail box on the MDS assessment. The facility did not have a specific MDS policy but followed the Resident Assessment Instrument (RAI) guidelines. The inaccurate MDS assessment was not reflected in the resident's care plan or actual care provided.