Inaccurate Documentation of Cognitive Assessment
Penalty
Summary
The facility failed to ensure that the clinical records for a resident, identified as R37, were complete and accurately documented. The resident was admitted with diagnoses including repeated falls, diabetes, and low blood pressure. The Minimum Data Set (MDS) assessments, which are mandated to evaluate a resident's abilities and care needs, showed discrepancies in the Brief Interview of Mental Status (BIMS) scores over time. Initially, the BIMS score was recorded as 15, indicating the resident was cognitively intact. However, subsequent MDS assessments showed a decline in the BIMS score to 12 and then to 10, suggesting moderate cognitive impairment. Despite these changes in the MDS assessments, the clinical record progress notes consistently documented a BIMS score of 15, indicating no cognitive impairment. This inconsistency was confirmed by the Director of Nursing (DON) during an interview, who acknowledged the failure to ensure accurate and complete documentation for the resident. The facility did not have a specific policy for documentation in clinical records, contributing to the deficiency.
Plan Of Correction
I. R37 BIMS score was updated by the Nurse Practitioner under the Palliative Care Note. II. Facility Nurse Practitioner(s) will conduct a full facility sweep to ensure all residents BIMS scores are updated and correctly documented. Moving forward, facility nurse practitioner(s) will ensure their documentation is current and updated in the resident charts. III. Director of Nursing/Director will re-educate the facility Nurse Practitioner(s) on clinical records are complete and accurate. IV. Director of Nursing/Designee will conduct random audits of 10 residents weekly for 8 weeks to ensure nurse practitioner(s) are documenting the correct BIMS score on residents. Audit results will be taken through Quality Assurance Committee meeting for tracking and trending purposes.