Failure to Accurately Document External Catheter Use on MDS Assessment
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for one resident upon admission and subsequent assessment. The resident was admitted with diagnoses including adult failure to thrive, chronic heart failure, and a need for assistance with personal care. Review of the resident’s MDS assessment, specifically section H, showed that staff documented the resident as not using an external catheter. However, during an observation of the resident’s room, surveyors noted a canister with what appeared to be urine collecting, and the resident confirmed in an interview that the canister was connected to an external catheter that she had been using since before admission. In a later interview, the DON also confirmed that the resident utilized an external catheter and acknowledged that this device had not been included in the resident’s MDS assessment, despite it being in use.
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