Inaccurate MDS Assessment for Hospice Care
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for a resident, identified as Resident R30. The deficiency was identified through a review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews. Resident R30, who was admitted to the facility in January 2021, had a physician order dated March 2024 to be admitted to hospice services. However, the Significant Change MDS assessment dated April 2024 incorrectly indicated that the resident was not receiving hospice care during the assessment period. This inaccuracy was confirmed by the Registered Nurse Assessment Coordinator during an interview in January 2025.
Plan Of Correction
Resident # 30 MDS was immediately corrected to accurately reflect resident status. To identify other residents that have the potential to be affected, the MDS/designee completed an audit of current residents to ensure MDS assessments accurately reflect the resident status. Correction will be made as needed. To prevent this from recurring, the RDCS/designee educated MDS/nursing leadership on requirements of F641 and ensuring that resident MDS are updated and accurately reflect resident status. To monitor and maintain ongoing compliance, the DON/designee will audit 3 residents weekly x4 then monthly x 2 to ensure resident MDS accurately reflect resident status. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.