Inaccurate MDS Assessment of Resident's Personal Hygiene Needs
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's functional ability for personal hygiene on the Minimum Data Set (MDS), as required by facility policy. The resident in question was admitted with diagnoses including osteoarthritis, contracture, muscle weakness, and dementia, and was documented as severely impaired in cognitive skills for daily decision making. Multiple reviews of the resident's MDS indicated inconsistencies: while the MDS at one point recorded the resident as requiring only partial/moderate assistance with personal hygiene, other documentation, including care conference notes and subsequent MDS assessments, indicated the resident actually required substantial/maximal assistance. Observations of care and interviews with staff confirmed that the resident had consistently needed maximal assistance for personal hygiene for at least a year. Interviews with the DON and MDS Nurse revealed that the MDS had been inaccurately completed, listing a lower level of assistance than was actually required. Both acknowledged the importance of accurate MDS assessments for care planning. The facility's policy assigns responsibility for ensuring accurate and timely MDS submissions to the assessment coordinator or designee, in accordance with federal and state guidelines. The inaccurate assessment had the potential to impact the development and implementation of a resident-centered care plan tailored to the resident's actual needs.