Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two of twenty-eight sampled residents. For one resident, the MDS assessment incorrectly indicated the use of an anticoagulant during the look-back period, while the resident was actually prescribed and administered an antiplatelet medication, Clopidogrel Bisulfate, for blood clot prevention. The MDS coordinator acknowledged the error, stating that the assessment was miscoded despite efforts to ensure accuracy during completion. For another resident, discrepancies were found in the discharge assessment. The resident, who was cognitively intact and had diagnoses including anemia, urinary tract infection, and arthritis, experienced a medical emergency and was sent to the hospital, where a pulmonary embolism was diagnosed. The resident died at the hospital, but the MDS discharge assessment inaccurately documented the resident as having died in the facility. The MDS coordinator confirmed after reviewing the clinical record that the discharge should have reflected a transfer to the hospital rather than a death in the facility.