Inaccurate MDS Documentation and Assessment
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for several residents, leading to uncommunicated needs for care and services. For Resident 28, the MDS lacked documentation of a fall that occurred on 12/10/23, despite the resident's history of falls and unsteady gait. The facility's fall notes confirmed the incident, but the MDS did not reflect this, indicating a failure in accurate record-keeping and assessment. Additionally, the MDS coding was based on incomplete information, as assessments were not completed on time, and the facility lacked a policy for MDS completion, relying solely on the Resident Assessment Instrument (RAI) manual as a reference. Resident 24's MDS also contained inaccuracies, particularly regarding the use of oxygen and mobility aids. The Annual MDS did not document the resident's use of oxygen, despite physician orders and observations confirming its use. Similarly, the Quarterly MDS failed to document the resident's use of a wheelchair or walker for mobility. These discrepancies highlight a significant gap in the facility's assessment and documentation processes, potentially leading to unmet care needs for the resident. For Resident 25, the MDS and Care Area Assessments (CAAs) were incomplete and inaccurate, particularly concerning falls, urinary catheter use, and a contracture in the left hand. The MDS did not trigger a falls assessment, despite multiple documented falls and a high-risk evaluation. The CAAs lacked analysis of findings, merely restating codes without addressing underlying issues. The care plan did not identify the resident's left-hand contracture, and there were no specific orders for safety or falls prevention. This lack of comprehensive assessment and accurate documentation could lead to negative psychosocial effects and uncommunicated needs for the resident.
Penalty
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A resident with severe cognitive impairment and multiple diagnoses was documented in medical and dental assessments as having natural teeth with missing teeth and no dentures, while staff interviews revealed the resident actually had partial dentures. This inconsistency between staff knowledge and assessment documentation resulted in a deficiency related to inaccurate resident assessments.
A resident with diabetes and anxiety was documented in MDS assessments as having no dental issues, but was observed to be without natural upper teeth and reported losing teeth since admission without being offered dental assistance. Interviews with the MDS RN, an LPN, and the DON confirmed the inaccuracy of the resident's dental status in the MDS.
A resident was admitted with complex medical conditions and hospital records indicating buttock wounds, but the facility's admission assessment did not document these wounds. The MDS nurse, relying solely on hospital documentation and without conducting a personal assessment, recorded pressure injuries that were not present according to the facility's clinical evaluation. The discrepancy between hospital and facility findings was not addressed before completing the MDS assessment.
The facility did not accurately complete MDS 3.0 assessments for two residents, resulting in incorrect documentation of discharge status and failure to record multiple vascular wounds and pressure ulcers. These deficiencies were confirmed through medical record review and staff interviews.
A resident with dementia and a history of wandering and aggressive behaviors was admitted to the secure/memory care unit without an assessment to determine appropriateness for placement. The DON confirmed that the required assessment was not completed prior to admission, and only after placement was the resident's severe mentation impairment and exit-seeking behavior documented. This deficiency was identified during a complaint investigation.
A resident with dementia and behavioral disorders was discharged after the closure of a secured unit, with the process planned and coordinated with the family. However, the MDS assessment was inaccurately coded as an unplanned discharge due to a delay in the moving date, despite CMS guidelines indicating the discharge was planned.
Failure to Complete Accurate Dental Assessments
Penalty
Summary
The facility failed to ensure accurate assessments were completed for a resident with multiple diagnoses, including psychotic disorder with delusions, Parkinson's disease, anxiety, depression, dementia, and neurocognitive disorder with Lewy bodies. Medical record review showed that nursing admission and dental assessments consistently documented the resident as having natural teeth with missing teeth and no dentures. However, during staff interviews, a CNA reported that the resident had partial dentures, which was confirmed by the unit manager upon review of the assessments. The Minimum Data Set (MDS) assessment also indicated the resident had no broken or loosely fitting dentures and no mouth or facial pain, discomfort, or difficulty chewing. This discrepancy between staff knowledge and documented assessments led to the deficiency.
Inaccurate MDS Assessment of Oral/Dental Status
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for one resident out of four reviewed. A resident admitted with diagnoses including type II diabetes mellitus with polyneuropathy and generalized anxiety was documented in quarterly MDS assessments as having no oral or dental issues. However, observation revealed the resident was without natural upper teeth, and the resident reported losing several teeth since admission and not being offered assistance to see a dentist. Interviews with the MDS RN and an LPN confirmed uncertainty and inaccuracy regarding the resident's dental status, and the Director of Nursing acknowledged the MDS assessment did not accurately reflect the resident's oral or dental condition.
Inaccurate Admission MDS Skin Assessment Due to Unresolved Documentation Discrepancy
Penalty
Summary
The facility failed to ensure the accuracy of an admission Minimum Data Set (MDS) skin condition assessment for one resident. Upon review, the resident was admitted with diagnoses including surgical aftercare, colostomy status, pulmonary embolism, and malignant neoplasm of the colon. Hospital discharge documentation indicated the presence of a right buttock wound and a left buttock deep tissue injury. However, the facility's admission wound assessment, completed by the Director of Nursing (DON), documented only a surgical incision to the abdomen and a stage two pressure ulcer of the left axilla, with no mention of wounds to the buttocks. The admission MDS assessment, completed by an MDS Registered Nurse who had not personally assessed the resident, recorded a stage two pressure ulcer and a deep tissue injury based solely on hospital documentation. During interviews, the MDS nurse admitted uncertainty about how to proceed when hospital records and clinical assessments did not align, as she was still in training. Subsequent observation and interviews confirmed the absence of pressure ulcers or deep tissue injuries on the buttocks at admission. The facility's policy required interdisciplinary participation in resident assessments, but the discrepancy between hospital and facility findings was not resolved prior to completing the MDS assessment.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) 3.0 assessments were completed accurately for two residents. For one resident, the MDS assessment indicated 'discharge return anticipated' after a hospital transfer, but the resident did not return to the facility. This error was confirmed by the MDS nurse during an interview. For the second resident, the initial nursing evaluation upon readmission did not address multiple vascular wounds to the left foot, and the five-day MDS assessment failed to document these wounds. Additionally, the resident's skin and wound evaluation noted an unstageable pressure ulcer on the right heel, but the assessment lacked wound measurements. Further review of the five-day MDS assessment for the second resident showed inconsistencies regarding cognitive status and assistance needs, and it did not address vascular wounds to the right toes. The MDS coordinator confirmed that the assessments did not reflect all existing wounds. These deficiencies were identified through medical record review and staff interviews during a complaint investigation.
Failure to Complete Assessment Prior to Secure Unit Placement
Penalty
Summary
The facility failed to complete an assessment prior to placing a resident on the secure/memory care unit. Record review showed that the resident was admitted with multiple diagnoses, including ataxia, dementia, psoriatic arthropathy, recurrent depressive disorder, wandering, and adult failure to thrive. The care plan identified the resident as an elopement risk due to behaviors such as pacing the halls and wandering into other resident rooms, and included interventions like checking the secure tech bracelet and encouraging family involvement. However, there was no evidence in the medical record that an assessment was conducted to determine the appropriateness of placement on the secure unit before admission. Interview with the DON confirmed that the assessment was not completed prior to the resident's admission to the secure unit. A functional assessment was only completed after the resident was already on the unit, which documented severe mentation impairment, uncooperative and resistive behaviors, wandering, verbal and physical abuse, social inappropriateness, and exit-seeking. The resident had a history of attempts to exit home, aggression, and had recently attempted to exit the building, triggering the alarm. This deficiency was identified during a complaint investigation.
Inaccurate MDS Assessment Coding for Discharge
Penalty
Summary
The facility failed to complete an accurate comprehensive assessment for a resident with Alzheimer's disease, schizoaffective disorder, and intermittent explosive disorder. The resident was admitted with a high risk for elopement, aggression, and required close supervision in a secured unit. Due to the closure of the secured unit, the resident and family were given a 30-day notice for discharge, as the resident's needs could not be met on the main floor. The discharge was scheduled and anticipated, with the family involved in planning and arranging for the resident's personal items to be moved. Despite the planned nature of the discharge, the Minimum Data Set (MDS) assessment was coded as an unplanned discharge by the RN, based on the discharge occurring a day later than originally scheduled. Interviews with staff confirmed that the delay was due to logistical reasons related to moving the resident's belongings, not due to an acute medical event or an unexpected decision by the resident. The Centers for Medicare and Medicaid Services (CMS) guidelines define an unplanned discharge as one resulting from an acute medical need or an unexpected departure, which did not apply in this case. This misclassification resulted in an inaccurate assessment for the resident.
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