Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were accurate and fully completed for seven out of eight residents. The deficiency was identified through a review of the Resident Assessment Instrument User's Manual, clinical records, and staff interviews. Specifically, the facility did not complete the Brief Interview for Mental Status (BIMS) and Resident Mood Interview for residents who were at least sometimes understood, as indicated in Section B: Hearing, Speech, and Vision of the MDS. This discrepancy was noted for residents R7, R21, R22, R24, R38, R43, and R60, whose assessments inaccurately reflected their cognitive and mood status. During interviews, the Registered Nurse Assessment Coordinator and the Nursing Home Administrator confirmed the inaccuracies in the MDS assessments. The assessments failed to align with the guidelines provided in the Long-Term Care Facility Resident Assessment Instrument User's Manual, which mandates that the BIMS and mood assessments be conducted if a resident is at least sometimes understood. This oversight resulted in incomplete and inaccurate assessments for the affected residents, compromising the accuracy of their documented care needs.
Plan Of Correction
1. MDS cannot be corrected. 2. and 3. Education will be completed with Social Services by the Regional Nurse Consultant on the accuracy of section B0700 and C0100 of the MDS. 4. Five random audits will be completed by RNAC or designee weekly for 4 weeks of residents MDS to ensure accuracy of sections B0700 and C0100. The QAPI committee will determine the need for further audits.