Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the clinical status of three residents. For one resident with diabetes mellitus, the admission MDS did not indicate the use of hypoglycemic medication, despite active orders and administration of insulin (Lantus) for diabetes management. Both the Director of Clinical Records (DOCR) and the Director of Nursing (DON) acknowledged that the omission was an error and that the MDS should have accurately documented the use of insulin as a high-risk medication. Another resident with a flaccid neuropathic bladder and a suprapubic catheter had their Quarterly MDS assessment incorrectly coded. Although the resident had an indwelling catheter, the assessment was marked as "Always incontinent" instead of "Not rated" as required by the CMS RAI Manual for residents with catheters during the look-back period. The MDS coordinator and DOCR confirmed the miscoding, and the DON stated that MDS accuracy was the responsibility of the MDS coordinator. A third resident, diagnosed with depression and prescribed mirtazapine, had their quarterly MDS assessment coded as not receiving antidepressants, despite physician orders and medication administration records confirming ongoing antidepressant therapy. The MDS coordinator acknowledged the error, stating the resident should have been coded as receiving an antidepressant. Facility policy and CMS regulations require accurate and comprehensive assessments to ensure proper care planning and service delivery.