Inaccurate MDS Assessments for Pressure Ulcers and Dialysis
Penalty
Summary
The facility failed to ensure that comprehensive assessments accurately reflected the current status of three residents. For one resident, the Minimum Data Set (MDS) assessment did not indicate the presence of an active Stage 3 pressure ulcer, despite documentation in the care plan, progress notes, physician wound consults, and physician orders confirming the existence and treatment of the wound. Another resident's MDS inaccurately indicated that the resident was receiving dialysis, although there was no diagnosis, care plan focus, or physician order for dialysis, and the resident's face sheet did not list end-stage kidney disease. A third resident's MDS failed to reflect an active unstageable pressure injury, even though the care plan, physician consults, and orders documented the presence and treatment of pressure injuries to the heels. Interviews with facility staff, including the MDS Coordinator, DON, and Administrator, revealed a lack of awareness regarding the discrepancies in the MDS assessments. The MDS Coordinator acknowledged that the MDS should be updated within 14 days after a significant change in condition, such as the development of a new pressure ulcer, and admitted that the errors were due to human error and lack of team communication. The DON and Administrator also confirmed the importance of maintaining accurate and current MDS assessments and recognized that the errors had not been identified prior to the survey. Review of the facility's documentation and the CMS Resident Assessment Instrument (RAI) Manual confirmed that significant changes, such as new pressure ulcers or errors in previous assessments, require timely updates and corrections to the MDS. The facility did not have a specific policy for MDS accuracy beyond following the CMS RAI Manual. The errors in the MDS assessments resulted in inaccurate information being available for care planning and management, as reflected in the facility's resident matrix and other records.