Failure to Accurately Reflect Resident Diagnoses and Treatments in MDS Assessments
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current status of two residents. For one resident, the facility did not identify a diagnosis of Parkinson's Disease in the Quarterly Minimum Data Set (MDS) and the list of medical diagnoses, despite multiple sources indicating the presence of this condition. The resident's face sheet, care plan, physician's orders, and medication administration record all referenced Parkinson's Disease, and the resident was observed experiencing tremors consistent with the diagnosis. However, the MDS listed only unspecified parkinsonism, omitting the specific diagnosis of Parkinson's Disease. For another resident, the facility did not document the use of oxygen therapy in the MDS, even though the resident was observed receiving oxygen via nasal cannula and had an active physician's order for oxygen administration as needed for respiratory symptoms. The care plan addressed related issues such as pneumonia and breathing treatments but did not include a focus area for oxygen administration. Both the Quarterly and Change of Condition MDS assessments failed to indicate the resident's use of oxygen. Interviews with facility staff confirmed that the MDS nurse was responsible for entering diagnoses and treatment information into the MDS and diagnosis list, using information from medical records and physician documentation. The nurse acknowledged that the omission of the Parkinson's Disease diagnosis and the failure to document oxygen use in the MDS were errors, as these were active problems being treated in the facility and should have been included in the residents' assessments.