Inaccurate MDS Assessment of Hospice Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's hospice status. The resident was admitted with diagnoses including heart failure, depression, and anxiety disorder, and had an active physician order for hospice care from the time of admission. The resident's care plan and order summary both indicated hospice care, and interviews with the resident, a Licensed Vocational Nurse, and the MDS Coordinator confirmed that hospice services had been provided since admission. However, the MDS assessment did not indicate that the resident was on hospice care while residing in the facility. This discrepancy was identified during a review of the resident's records and confirmed through staff interviews. The facility's policy requires that documentation in the medical record be objective, complete, and accurate, and federal regulations mandate that the assessment accurately reflect the resident's status. The inaccurate coding of the MDS assessment resulted in a failure to properly document the resident's hospice status.