Inaccurate MDS Assessments for Antibiotic Use, Oxygen Therapy, and Edema
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents, resulting in omissions of current clinical conditions and treatments. For one resident with type 2 diabetes mellitus, traumatic brain injury, quadriplegia, obstructive and reflux uropathy, and a need for assistance with personal care, the record showed a physician’s order for Nitrofurantoin 100 mg for UTI prophylaxis. However, review of this resident’s MDS dated [DATE] showed that antibiotic use was not checked, and the MDS Coordinator confirmed during interview that the resident was currently taking an antibiotic and that she failed to capture this on the assessment. Another resident with COPD, Alzheimer’s disease, dementia with agitation, major depressive disorder, and hypertension was observed with an oxygen concentrator at the bedside, and physician orders documented oxygen at 2 L/min via nasal cannula as needed for respiratory distress. The resident’s MDS dated [DATE] contained no indication of oxygen use, and the DON confirmed the resident does utilize oxygen as needed and that the MDS was not accurate. A third resident with Parkinsonism, severe dementia, obstructive and reflux uropathy, wasting disease, and sarcopenia was observed asleep in a wheelchair with red, swollen legs and ankles. A physician progress note documented a diagnosis of ankle edema, but the MDS dated [DATE] did not indicate ankle edema. The DON confirmed that this resident does have ankle edema and that the MDS assessment was not accurate.
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