Inaccurate MDS Assessment Documentation
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's current status. Specifically, a male resident with diagnoses including Schizophrenia, Cerebral Palsy, and Dementia was not properly coded on his quarterly MDS assessment. The assessment omitted the diagnosis of Schizophrenia in the active diagnoses section, did not indicate the use of a lidocaine patch for pain management, and failed to record the administration of an antibiotic, Cipro, which the resident received during the look-back period. These omissions were identified through interviews and a review of the resident's medical records, including the Medication Administration Record (MAR) and the electronic medical record (EMR). The MDS Nurse, who was responsible for completing the assessment, acknowledged during an interview that the resident's Schizophrenia diagnosis, use of a lidocaine patch, and antibiotic administration should have been coded on the MDS. The nurse confirmed that information for the MDS is obtained through record review and that the look-back periods for diagnoses and medications were not properly followed in this case. The facility's policy requires all personnel completing any portion of the MDS to certify its accuracy, but this was not adhered to for this resident's assessment.