Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that each resident received an accurate assessment reflective of their current status for two residents reviewed for Minimum Data Set (MDS) assessments. For one resident with a diagnosis of neurogenic bladder and physician orders for a suprapubic catheter and related care, the quarterly MDS assessment incorrectly documented that the resident did not have an indwelling catheter. This discrepancy was identified through review of physician orders and confirmed during an interview with the MDS Coordinator, who acknowledged the resident did have a catheter and was unsure why it was coded otherwise. For another resident, staff interviews and progress notes indicated that the resident required assistance with eating and was dependent during meals, as documented by dietary notes. However, the MDS assessment for this resident inaccurately coded the resident as independent in eating. This inconsistency was confirmed by two Certified Nursing Assistants and the MDS Coordinator, who stated that the error was due to incorrect coding. These findings demonstrate that the facility did not ensure the accuracy of MDS assessments as required by their policy and procedures.