Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the current status of three residents. For one resident, the quarterly MDS assessment did not document three separate falls, each resulting in varying degrees of injury, that occurred on specific dates. Another resident's quarterly MDS assessment omitted documentation of an incident involving physical aggression. Additionally, a third resident's quarterly MDS assessment failed to record behaviors such as delusions, refusal of care, and a fall that resulted in minor injury. These omissions were identified through observations, interviews, and record reviews, indicating that the assessments did not accurately capture the residents' conditions and events as required.