Inaccurate Resident Assessment in MDS
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's status during a recertification survey. Specifically, the Quarterly Minimum Data Set (MDS) assessment for a resident inaccurately documented the resident as comatose, despite evidence to the contrary. The resident, who was diagnosed with Dementia and Depression, was observed to be interactive and responsive, as evidenced by their ability to smile and wave at a surveyor. Additionally, a Comprehensive Care Plan indicated the resident could make themselves understood, and a physician's order included a floor ambulation program, further contradicting the comatose status recorded in the MDS. The error was attributed to Social Worker #1, who was responsible for completing the MDS Section B (Hearing, Speech, and Vision) and admitted to mistakenly documenting the resident's status as comatose. The Minimum Data Set Assessment Coordinator acknowledged the error, stating that they do not review individual sections of the MDS for accuracy, only for completion. This oversight led to the inaccurate assessment being recorded, which was not aligned with the resident's actual condition and capabilities.
Plan Of Correction
Plan of Correction: Approved February 12, 2025 A: Immediate Correction Action 1. Resident #128 who still resides at the facility was not affected by this deficient practice. 2. The MDS for resident #128 was corrected to reflect “0” on 1/24/2025. 3. Social Worker #1 was re-educated on MDS accuracy by the RN Nurse Educator. B: Identification of Others 1. All residents that reside in the facility have the potential to be affected by this deficient practice. 2. The facility ran a report on Section B, question B0100 to see if any other residents were coded incorrectly and there was no inaccurate finding. C: Systematic Review to prevent re-occurrence 1. The facilities policy titled Minimum Data Set Completion Assignment dated 10/18/2023 was reviewed by the Administrator, Medical Director and DNS and no changes were made. 2. The RN Nurse Educator will re-educate all staff that are assigned to complete the MDS assessment on MDS Assessment Accuracy. D: Quality Assurance 1. The DNS devised an audit tool to ensure that all MDS Assessments are accurate. 2. The DNS and or designee will audit 10 MDS assessments section B question B0100 weekly x 3 months and monthly thereafter for 1 year until 100% compliance is obtained to ensure that the MDS accuracy. 3. Any negative audit findings will immediately be addressed by the DNS/ designee with an onsite teaching/in-service, and disciplinary action as needed. 4. The DNS will report the findings of this audit quarterly at the QAPI meeting. 5. The DNS/ designee is responsible for ensuring the correction of this deficient practice.