Inaccurate Resident Assessments Documented in MDS
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the actual conditions and care provided to six out of nineteen residents reviewed. For one resident with a stage 4 pressure ulcer, the Minimum Data Set (MDS) was incorrectly coded to indicate the resident was not at risk for pressure ulcers, despite clinical records showing otherwise. Another resident with chronic kidney disease, vascular dementia, and a history of weight loss was not coded as receiving a therapeutic diet or hospice care on multiple MDS assessments, even though physician orders and clinical records confirmed these services were being provided. A third resident with atrial fibrillation and chronic respiratory failure was actively receiving an antipsychotic medication, but the MDS did not reflect this medication use. In another case, a resident with a gastrostomy and feeding difficulties was incorrectly coded as having received intravenous fluids, though no documentation supported this. Additionally, a resident admitted to hospice care for chronic respiratory failure and hypoxia was not coded as having an active diagnosis of respiratory failure on the MDS. Finally, a resident with type II diabetes and chronic respiratory failure was coded as receiving insulin injections, but records showed only Ozempic injections were administered, not insulin. These inaccuracies were confirmed through staff interviews, with the Director of Nursing acknowledging the errors in MDS coding for each case. The deficiencies were identified through clinical record reviews and staff interviews, demonstrating a pattern of inaccurate resident assessments that did not align with the residents' actual diagnoses, treatments, and care needs as documented in their clinical records.