Inaccurate MDS Diagnoses and Lack of RN Validation for Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) assessments accurately reflected residents’ diagnoses and were properly reviewed and signed by a Registered Nurse (RN). For one resident, the face sheet listed diagnoses including cerebral infarction, gastro-esophageal reflux disease (GERD), and hypothyroidism, while the care plan incorrectly documented hyperthyroidism instead of hypothyroidism. The quarterly MDS assessment for this resident showed a BIMS score of 10, indicating moderate cognitive impairment, but did not list either hypo- or hyperthyroidism or GERD as diagnoses, despite the resident being treated with protonix for GERD and levothyroxine for hypothyroidism. The facility’s own policy required that assessments accurately reflect the resident’s status. The same quarterly MDS assessment for this resident was signed in section Z0500 by the MDS Coordinator, who is an LVN, under the field designated for the RN Assessment Coordinator verifying assessment completion, and there was no RN signature. A second resident’s face sheet listed diagnoses including acute kidney failure, essential hypertension, and rheumatoid arthritis, and her quarterly MDS assessment showed a BIMS score of 13 with total functional dependence for movement. That assessment was also signed in section Z0500 by the LVN MDS Coordinator as the RN Assessment Coordinator, with no RN signature present. Facility policy stated that a registered nurse must conduct or coordinate each assessment. In interviews, the LVN MDS Coordinator stated he was responsible for MDS assessments and care plans and confirmed that GERD and hypothyroidism were active, treated diagnoses for the first resident that were not included on the MDS. He explained that active diagnoses usually auto-populate into the MDS and that he did not see a button to add GERD or hypothyroidism, and acknowledged he should have written them in under “other,” describing the omission as an oversight. He also confirmed he was aware that MDS assessments required RN review and signature, and suggested that he may have signed assessments as completed to check for errors and failed to unmark them as incomplete. The DON stated that all active diagnoses should be included for accuracy, that an RN must sign and validate MDS assessments, and that an LVN could not sign them, but she could not explain why the two residents’ assessments lacked RN signatures or why the first resident’s GERD and hypothyroidism diagnoses were missing from the MDS.
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