Inaccurate Comprehensive Assessments for Residents
Penalty
Summary
The facility failed to conduct accurate comprehensive assessments for four residents, as required by regulations. Resident #4's quarterly Minimum Data Set (MDS) assessment did not have the necessary sections on functional abilities completed. Similarly, Resident #46 and Resident #64's MDS assessments were missing required sections on functional abilities, which should have been completed during their respective quarterly and annual assessments. These omissions were confirmed by the Medicare Case Manager during an interview. Resident #22's case highlighted discrepancies between the clinical records and the MDS assessment. Despite having a diagnosis of dysphagia and being on a prescribed puree mechanically altered diet with nectar-thickened liquids, Resident #22's MDS indicated no swallowing issues and no mechanically altered diet. Observations and interviews confirmed that Resident #22 was indeed on a puree diet with nectar-thickened liquids, contradicting the MDS assessment. This inconsistency was acknowledged by the Medicare Case Manager, who confirmed the inaccuracies in the MDS documentation.