Inaccurate MDS Assessment Documentation
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident. Specifically, the MDS assessment did not accurately reflect the resident's history of falls and the use of side rails for bed mobility and transfers. The resident, who was admitted with multiple diagnoses including chronic peripheral insufficiency, type 2 diabetes with skin complications, unilateral osteoarthritis of the left knee, generalized muscle weakness, need for assistance with personal care, and unspecified dementia with agitation, experienced several falls as documented in the facility's incident list. Despite these incidents and physician's orders for the use of 2 1/4 side rails to assist with mobility and independence, the MDS admission assessment failed to document a fall with injury and the use of side rails. The MDS coordinator confirmed during an interview that these details should have been included in the resident's assessment, indicating a lapse in accurately capturing the resident's needs and care requirements.