Inaccurate and Incomplete MDS Assessments
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were accurate and fully completed for seven out of ten residents. The deficiencies were identified through a review of the Resident Assessment Instrument User's Manual, clinical records, and staff interviews. The manual specifies that certain sections of the MDS, such as Section C: Cognitive Patterns and Section D: Mood, should be completed based on the resident's ability to be understood. However, for several residents, these sections were either inaccurately coded or marked as 'Not Assessed,' despite indications that assessments should have been conducted. For instance, Resident R8 was noted as 'sometimes understood' in Section B: Hearing, Speech, and Vision, yet Sections C and D were marked as 'rarely understood,' and the necessary assessments were not completed. Similarly, other residents, such as R10, R13, R29, R36, R40, and R54, had incomplete or inaccurately coded assessments, with critical sections left unassessed. The Resident Nurse Assessment Coordinator confirmed these findings, acknowledging the facility's failure to complete the MDS assessments accurately.
Plan Of Correction
Resident 8, 10, 13, 29, 36, 40, and 54 was reassessed to include Section C and BIMS be conducted. The facility has determined that all residents have the potential to be affected. A house audit has been completed to ensure that section C and BIMS were completed appropriately. An in-service education program was conducted by the Director of Nursing Services or designee with MDS Coordinator(s) and Social Service to addressing the importance of making certain that the comprehensive minimum data set assessments were accurate and fully completed. The Director of Nursing Services, or designee, will conduct a random audit of five (5) residents per week on their MDS for four (4) consecutive weeks. These residents and their medical records will be assessed to ensure that the BIMS section is completed correctly in the MDS. This plan of correction will be monitored at the monthly Quality Assurance meeting until such a time consistent substantial compliance has been met.