Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for four out of twelve residents. The Resident Assessment Instrument (RAI) User's Manual provides specific instructions for completing Minimum Data Set (MDS) assessments, including the Brief Interview for Mental Status (BIMS) and weight loss coding. However, the facility did not adhere to these guidelines, resulting in inaccurate assessments. For instance, Resident R51's MDS indicated that a BIMS interview should be conducted, but the section was left incomplete with dashes. Similarly, Residents R90 and R117 were also supposed to receive BIMS interviews, but their assessments were similarly incomplete. Resident R164's assessment inaccurately indicated that the resident was on a physician-prescribed weight-loss regimen. The clinical records did not support this claim, as there was no documentation from physicians or nutritionists indicating such a regimen. The Registered Dietitian and Registered Nurse Assessment Coordinator confirmed that the weight loss information was entered in error. This discrepancy highlights a failure in accurately documenting the resident's nutritional status. Interviews with facility staff, including the Director of Social Services and the Vice President of Clinical Services, confirmed the inaccuracies in the assessments. The staff acknowledged the errors and the failure to follow the RAI guidelines, which led to the inaccurate documentation of the residents' cognitive and nutritional statuses. These inaccuracies in the MDS assessments reflect a significant oversight in the facility's responsibility to maintain accurate clinical records.
Plan Of Correction
Residents R90, R117, R164 experienced no negative effects of the deficient practice. Resident R64 no longer resides in the facility. RNAC will educate the Social Workers on proper completion of BIMS Assessment per the RAI guidelines. RNAC will educate the Dietitian and CDM on how to determine significant weight loss, how to determine when a significant weight loss occurs, and when to code if a weight loss is physician prescribed per RAI guidelines. The RNAC will audit all new MDS assessments weekly for one month, and then 12 MDS Assessments weekly for one month to ensure accuracy of the MDS. Audits and education will be submitted to the QAPI Committee for review and approval.