Failure to Accurately Reflect Resident Diagnoses in MDS Assessment
Penalty
Summary
The facility failed to ensure that each resident's assessment accurately reflected their status and that all individuals completing portions of the assessment signed and certified the accuracy of their contributions. Specifically, for one resident, the admission Minimum Data Set (MDS) assessment did not include a diagnosis of diabetes, despite the resident being prescribed and administered diabetic medications such as insulin and metformin. The resident's medical records, care plan, physician's orders, and medication administration records all indicated active treatment for diabetes, but this diagnosis was omitted from the MDS assessment. Additionally, there was no care plan addressing diabetes for this resident. Interviews with facility staff, including the Regional MDS Coordinator, Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator, revealed a lack of awareness regarding the omission and uncertainty about how the error occurred. The MDS Coordinator acknowledged responsibility for ensuring assessment accuracy, while the DON and Administrator indicated that the interdisciplinary team (IDT) and clinical leadership were responsible for maintaining accurate records. The omission was not identified until the survey, and staff could not explain how the resident's diabetes diagnosis was missed from the assessment.