Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents. For one resident with a history of seizures, traumatic brain injury, dementia with behavioral disturbance, and delirium, incident reports and electronic medical records documented unwitnessed falls and the administration of antipsychotic medication. However, multiple MDS assessments did not indicate any falls in the relevant periods, nor did they accurately record the use of antipsychotic medication, despite physician orders and medication administration records showing otherwise. Another resident with Parkinson's disease and severely impaired cognition experienced falls, including one with injury, as documented in the care plan and electronic medical record. Despite this, the resident's quarterly MDS assessment failed to accurately reflect the occurrence of these falls. Staff interviews confirmed that the MDS assessments for both residents did not accurately represent their clinical status as required.