Inaccurate MDS Assessments at Forest City Nursing and Rehab Center
Penalty
Summary
Forest City Nursing and Rehab Center was found to be non-compliant with the requirement for the accuracy of assessments as per 42 CFR Part 483, Subpart B. The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of three residents. For one resident, the weight used in the MDS assessment was outdated, having been recorded more than 30 days prior to the assessment reference date, contrary to the MDS instructions. The Registered Dietitian (RD) admitted to being unaware of the requirement to code a dash for missing data and mistakenly used the outdated weight. Another resident's MDS assessment inaccurately indicated a significant weight loss, despite the resident being admitted only two days before the assessment, with no supporting evidence of such weight loss in the clinical record. Similarly, a third resident's MDS assessment incorrectly reported a weight loss, although the resident had been newly admitted just four days before the assessment. The RD confirmed that errors were present in the MDS assessments, as she had been using self-reported weights or hospital data instead of documented facility weight records.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely because it is by the provisions of federal and state law. The plan of correction represents the facility's credible allegation of compliance. The facility cannot retroactively obtain a weight for Resident 7 for the required timeframe for MDS coding. A modification MDS will be completed. Resident 42's weight change reported on the 11/7/24 MDS was calculated by the 10/27/24 hospital weight of 125 pounds and upon admission weight 11/5/24 of 116.6 which results in a 6.7% weight loss which is more than 5% in the past 30 days as per the RAI manual instructions. Resident 17's weight change reported on December 30, 2024, MDS was calculated by the 12/15/24 hospital weight of 169 pounds compared to the 12/26/24 facility obtained weight of 159.4 pounds which results in a 5.5 % weight loss in 30 days as per the RAI manual instructions. The last 30-day lookback audit will be completed to ensure proper weights were entered on the MDS. The RD will be educated on proper and accurate coding of weights and weight changes on the MDS. The RD will be given the list of obtained weights on a monthly/weekly/daily basis as obtained. She will code the MDS as per the weights obtained. An audit will be completed of 5 random resident weights compared to MDS entry weekly x 1 month and then 10 resident's MDS monthly x 2. The results of the audits will be reviewed at monthly QAPI x 3 months.