Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the current status and diagnoses of two residents. For one resident, the quarterly MDS completed after readmission did not indicate the presence of a colostomy, despite documentation in the care plan and previous MDS, as well as confirmation from the resident and staff that the colostomy appliance was in place and being managed. The MDS Coordinator acknowledged that the ostomy status should have been selected and was unsure why it was missed. For another resident, the quarterly MDS did not include a diagnosis of attention deficit hyperactivity disorder (ADHD), even though this diagnosis was documented in psychological assessments, the care plan, and confirmed by the resident, the Social Services Director, and the DON. The Social Services Director noted that the diagnosis should have been added to the electronic health record, and the MDS Coordinator confirmed it was not included in the MDS. The DON indicated that the omission may have occurred during a transition to a new electronic health record system and emphasized the responsibility of nursing and the MDS Coordinator to ensure accurate and updated diagnoses during admission and readmission. Interviews with staff and review of facility policy confirmed that comprehensive and accurate assessments are required at specified intervals. The failure to accurately code the colostomy and include the ADHD diagnosis in the MDS assessments resulted in incomplete documentation of the residents' needs and conditions.