Inaccurate Resident Assessments and Medication Documentation
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current status of multiple residents, as evidenced by discrepancies in the Minimum Data Set (MDS) documentation and medication records. For several residents, the MDS assessments did not include accurate information regarding skin conditions, medication usage, and primary diagnoses. For example, one resident's significant change MDS incorrectly documented the presence of unhealed pressure ulcers, despite care plans and physician orders indicating ongoing skin care interventions. Another resident's quarterly MDS omitted documentation of pain and antiplatelet medication, even though these medications were actively prescribed and administered, as shown in the Medication Administration Records (MAR) and care plans. Additional deficiencies were observed in the documentation of antidepressant and antiplatelet medication use for other residents. In one case, a resident's MDS failed to reflect the use of both antidepressant and antiplatelet medications, despite active orders and administration records confirming their use. Similarly, another resident's MDS did not document the use of prescribed antidepressant medications, even though the care plan and MAR indicated regular administration of these drugs. These omissions were confirmed through interviews with the MDS Case Manager and Director of Nursing (DON), who acknowledged the importance of accurate MDS documentation and the expectation that staff use available medical records to complete assessments. The facility also failed to accurately code a resident's primary diagnosis and mental illness status on the MDS and PASARR Level 1 Screening. One resident was incorrectly coded with a primary diagnosis of dementia and no mental illness, despite having a documented diagnosis of bipolar disorder. Interviews with facility staff revealed a lack of clarity regarding the process for verifying and correcting PASARR assessments, as well as uncertainty about the identification of primary versus secondary diagnoses. Facility policies required review of PASARR forms for accuracy prior to admission, but documentation and interviews indicated this process was not consistently followed.