Failure to Accurately Document Respiratory Treatments in MDS Assessments
Penalty
Summary
Facility staff failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the respiratory treatments being provided to several residents. Specifically, for three residents with significant cognitive impairment and complex medical conditions, the MDS did not document the respiratory treatments that were ordered and administered, such as nebulizer treatments and oxygen therapy. These omissions were identified through record reviews, observations, and interviews, which showed that the residents were receiving respiratory care that was not captured in their MDS assessments. For one resident, records indicated diagnoses of vascular dementia, acute respiratory issues with hypoxia, and atherosclerotic heart disease. The resident was dependent on staff for all activities of daily living and was receiving nebulizer treatments for wheezing, as confirmed by medication administration records and the resident's own statements. However, the MDS did not reflect these respiratory treatments. Similar findings were noted for two other residents with severe cognitive impairment and terminal illnesses, both of whom were dependent on staff and receiving respiratory treatments such as oxygen therapy and inhaled medications, but whose MDS assessments also failed to document these interventions. Interviews with facility leadership, including the DON and Administrator, confirmed that the expectation was for the MDS to accurately reflect all care and treatments provided, and that failure to do so could result in residents missing necessary care. The facility's policy on maintaining MDS assessments did not address the requirement for accuracy in documenting treatments. The MDS coordinator was not available for interview at the time the deficiency was identified.