Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to complete accurate Minimum Data Set (MDS) assessments for multiple residents, resulting in discrepancies between documented assessments and residents’ actual conditions and treatments. One resident with documented impaired hearing, a care plan noting impaired communication due to hearing loss, and a physician’s order for an audiology consult was recorded on the MDS as having adequate hearing and requiring no hearing aids. Another resident with a physician’s order for Pregabalin, an anticonvulsant prescribed twice daily for chronic pain syndrome, was documented on the MDS as not taking anticonvulsant medications, despite the ongoing order. Additional inaccuracies were identified for two other residents. One resident admitted with multiple diagnoses, including COPD with acute exacerbation, vascular dementia, dysphagia, Crohn’s disease, and insomnia, had been discharged from the hospital with a CPAP machine and reported using it nightly since admission, yet the MDS indicated no CPAP use. Another resident with cerebral palsy and a care plan noting impaired communication, garbled speech, and difficulty making herself understood was documented on the MDS as having clear speech. In each case, the MDS coordinator or Interim DON confirmed that the MDS entries were incorrect based on the residents’ actual conditions and treatments.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.