The facility failed to accurately code MDS assessments for two residents. One resident with Alzheimer’s disease, major depression, anxiety, and a psychotic disorder had MDSs that did not indicate a Level II PASRR despite prior PASRR approval for an unlimited LTC stay, and the MDS coordinator acknowledged the error. Another resident admitted with PTSD had an admission MDS that did not mark PTSD as an active diagnosis, and the MDS coordinator acknowledged the diagnosis was present on admission and that psychiatric services had been provided.
Inaccurate MDS coding was found for PASRR status, insulin use, and psychotropic medications. Two residents with approved PASRR Level II determinations were coded as not having PASRR Level II, one resident receiving glargine and aspart insulin was coded as not receiving insulin, and two residents had incorrect psychotropic medication coding, including one coded for an anti-anxiety med that was not ordered and another coded as not receiving an antipsychotic despite an order for Rexulti. The MDS RN verified the errors, and the DON stated the MDS should be coded accurately.
A resident with PTSD and bipolar 2 disorder, who was receiving related medications, had a completed PASRR Level II assessment that was not accurately documented in the MDS assessment. Staff interviews revealed that the PASRR Level II information was not properly entered, with the RN coordinator confirming inaccuracies in both comprehensive and quarterly MDS assessments, despite facility policy requiring accurate and complete documentation.
The facility failed to accurately code MDS assessments for two residents using seat belts in their wheelchairs. One resident, with intact cognition, used a seat belt daily by choice, while the other, moderately cognitively impaired, rarely used it. Observations and interviews revealed discrepancies in MDS coding, with the director of nursing confirming the seat belts were coded as restraints, despite stating they were not used as such.
The facility failed to accurately code the MDS assessments for two residents. One resident, who received daily insulin injections, was inaccurately recorded as not receiving insulin. Another resident, with severe cognitive impairment and a high fall risk, had bed and chair alarms that were not correctly documented in the MDS assessment. The DON confirmed these inaccuracies.
A facility failed to accurately complete elopement risk evaluations for several residents, including one with dementia who eloped undetected due to a malfunctioning door alarm. Despite previous elopement incidents, the resident's risk was not updated in the care plan, and staff did not recognize the event as reportable.
A provider failed to accurately code MDS assessments for two residents, leading to documentation errors. One resident's pressure ulcers were not recorded in the MDS, and another resident was incorrectly noted to have a catheter. The MDS/RN responsible did not review necessary documentation or was unaware of the errors, relying on basic training and the RAI manual for guidance.
A resident was not accurately assessed for the safe self-administration of nebulized medication. She was left alone during treatments without proper education on using the nebulizer. The facility lacked an order for self-administration, and her care plan did not include it. Nurses were unaware of the facility's policy on self-administration, and the resident's ability to self-administer was not assessed.
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