Inaccurate MDS Documentation for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for three residents, as required by the Resident Assessment Instrument (RAI) Manual. For one resident with a history of Borderline Personality Disorder and Post Traumatic Stress Disorder, the quarterly MDS did not document the presence of a surgical wound on the left neck area, despite clinical records showing a wound evaluation by a specialty physician. For another resident admitted with a fractured clavicle and cellulitis, the quarterly MDS failed to record a fall that occurred during the assessment period, even though the clinical record documented the incident. Additionally, a third resident with a right artificial shoulder joint had three falls within the MDS assessment reference period, including one resulting in a forehead hematoma, but none of these falls were documented in the annual MDS. These inaccuracies were confirmed through clinical record reviews and staff interviews, where the Registered Nurse Assessment Coordinator acknowledged the omissions in the MDS documentation for all three residents.