Failure to Maintain 15 Months of MDS Assessments in Active Records
Summary
The facility staff failed to maintain fifteen months of Minimum Data Set (MDS) assessments in the resident's active clinical record for eight residents who had been admitted for more than 15 months. The facility's policy on MDS completion and submission timeframes, dated 2010, did not provide guidance on maintaining these assessments. The Resident Assessment Instrument (RAI) manual, dated October 2023, mandates that nursing homes must keep all resident assessments from the previous 15 months in the active record and use them to develop, review, and revise the resident's comprehensive plan of care. However, the records for residents #1, #7, #13, #17, #23, #24, #26, and #32 did not contain the required 15 months of MDS assessments. During an interview, the MDS nurse revealed that the assessments were stored in boxes in his/her office and the social worker's office, making them inaccessible to other staff when the MDS nurse was not present. The MDS nurse was unaware of the requirement to keep these assessments in the active record. The Administrator confirmed that MDS information and assessments should be in the residents' active records and readily accessible for at least seven years, indicating a lack of adherence to the regulatory requirements.
Penalty
Resources
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The facility failed to maintain 15 months of resident assessments in the medical records for six residents. The MDS assessments were either missing or not updated, and technical difficulties with the electronic medical record system were cited as the cause. CNAs did not refer to the residents' Care Plans or MDS for information, relying instead on verbal instructions and their own assessments.
The facility failed to maintain resident assessments completed within the previous 15 months in the residents' active medical records. Six residents' MDS assessments were stored in a locked cabinet in the DON/Owner's office, making them inaccessible to staff when needed. The facility's leadership admitted they were unaware that these assessments should be part of the master record in the residents' active medical records.
Failure to Maintain 15 Months of Resident Assessments
Penalty
Summary
The facility failed to maintain 15 months of resident assessments in the medical records for six residents. The survey revealed that the Minimum Data Set (MDS) assessments were either missing or not updated for the residents. For instance, one resident's MDS had not been updated since September of the previous year, and another resident's MDS had not been updated since July. Additionally, some residents had no MDS available in their medical records at all. The Assistant Director of Nursing and the MDS Nurse acknowledged the issue, citing problems with printing the documents due to technical difficulties with the electronic medical record system. Despite attempts to resolve the issue, including reporting it to the Regional MDS Coordinator and the Previous Administrator, the problem persisted, and the necessary documents were not printed and placed in the residents' charts. The Regional Director of Operations/Interim Administrator was unaware of the issue until the survey and stated that an audit of all resident charts would be conducted to ensure compliance. Interviews with Certified Nursing Assistants (CNAs) revealed that they did not refer to the residents' Care Plans or MDS for information on the care required, relying instead on verbal instructions from nurses and their own assessments. The facility's policy mandates that 15 months of OBRA MDS be kept in a resident's active clinical record, but this was not adhered to, leading to the deficiency. The facility's Comprehensive Assessment/MDS Policy emphasizes the importance of maintaining updated assessments to develop comprehensive care plans for residents, which was not followed in this case.
Failure to Maintain Resident Assessments in Active Medical Records
Penalty
Summary
The facility failed to ensure that all resident assessments completed within the previous 15 months were maintained in the residents' active medical records. This deficiency was identified for six residents (Resident #1, Resident #10, Resident #13, Resident #18, Resident #21, and Resident #35) whose MDS assessments were not accessible to staff and ready for review. The MDS assessments were stored in a locked cabinet in the Director of Nursing (DON)/Owner's office, which was only accessible when the DON/Owner was on-site. This practice resulted in the MDS assessments not being available for review when needed, as observed during the state surveyor's review of the residents' charts at the nurses' station, where no MDS assessments were found in any of the six residents' charts reviewed. During interviews, the DON/Owner and the Administrator/Owner acknowledged that the MDS assessments were not kept in the residents' medical records and were instead stored separately in a locked cabinet. The Administrator/Owner explained that a former medical records staff person, who no longer worked for the company, had removed many records from the resident charts, which should not have been removed. The facility's leadership admitted they were unaware that the MDS assessments should be maintained as part of the master record in the residents' active medical records. This oversight affected the facility's ability to provide timely access to essential resident assessments, potentially impacting the quality of care provided to the residents.
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