Inaccurate MDS Catheter Assessment: A resident with a suprapubic catheter for neurogenic bladder was observed with a catheter urine collection bag, but the quarterly MDS incorrectly indicated no indwelling urinary catheter. The MDS RN later confirmed the assessment should have reflected the catheter.
A resident’s MDS was coded for substantial/maximal assistance with sit-to-stands, chair/bed-to-chair transfers, and toilet transfers, but the ADL task documentation showed only independent, supervision, or partial/moderate assistance. Survey observation found the resident transferring with supervision/touching assistance, and both a NA and PTA stated the resident typically needed only supervision or stand-by assistance. The MDS Coordinator confirmed the MDS was not coded based on the NA task documentation.
A resident’s quarterly MDS failed to include epilepsy in Section I Current Diagnoses even though the diagnosis was documented in the medical record. During review with the MDS RN, she acknowledged that epilepsy should have been marked and was missed.
A resident was observed smoking with staff present, but the Annual MDS incorrectly coded current tobacco use as 0, indicating the resident did not smoke. The CRC confirmed the MDS error during interview.
Accurate resident assessment was not maintained when two residents had incorrect MDS coding. One resident receiving hospice had an MDS that did not reflect hospice care and incorrectly answered the prognosis item, and another resident with an unstageable pressure ulcer present on readmission had an MDS that incorrectly showed zero ulcers present on admission or reentry. The MDS Coordinator and DON confirmed both assessments were inaccurate.
A resident receiving hospice services for end-of-life care related to cerebral infarction had a quarterly MDS that did not indicate hospice status, even though the physician order, care plan, and hospice communication book all showed hospice involvement. The MDS nurse confirmed the assessment was incorrect.
Incomplete and inaccurate MDS assessments were identified for two residents. One resident’s MDS incorrectly coded a wound infection, and another resident’s quarterly MDS incorrectly coded a hip fracture and other fracture, even though the medical record did not support those diagnoses during the look-back period. An LPN and the Administrator confirmed the coding errors were pulled from older MDS records.
Inaccurate discharge MDS assessment: A resident was discharged from the facility and was not expected to return, but the MDS stated that return was anticipated. A corporate nurse confirmed the resident did not return.
Inaccurate MDS for Toileting Schedule: A resident’s care plan included a toileting schedule upon rising, before and after meals, and at bedtime, but the significant change MDS marked “no” for both the urinary and bowel toileting programs. The MDS coordinator and DON confirmed the mismatch between the care plan and the MDS.
The facility failed to ensure the MDS accurately reflected the condition of two residents. One resident's MDS showed ambulation and omitted fractures, even though PT records and the PTA indicated the resident could not walk and had metatarsal fractures. Another resident's MDS listed walking 10 feet with supervision, but PT records and the PTA stated the resident had not walked in years; the Administrator confirmed the MDS was inaccurate.
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