Inaccurate MDS Assessment Due to Incorrect Weight Documentation
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for a resident by entering incorrect information in Section K0200 (weight) and Section K0300 (weight loss). The MDS nurse used a weight measurement of 265 lbs. from January, which was not within the required 30-day window of the assessment reference date in April. This led to an inaccurate entry for the resident's current weight and, subsequently, an incorrect assessment of weight loss status. The resident in question had a medical history that included hypothyroidism, diabetes mellitus, hypertension, and morbid obesity. The resident had been refusing to be weighed, and the last recorded weight was from January, as noted in the dietary progress notes. Despite this, the MDS nurse did not use the appropriate 'no information' code as instructed by the facility's policy and the CMS Resident Assessment Instrument (RAI) manual. Instead, the nurse entered the outdated weight to proceed with the MDS process, resulting in inaccurate data being recorded. Interviews and record reviews revealed that the MDS nurse was unaware of the resident's refusal to be weighed and acknowledged confusion regarding which weight to use. The nurse admitted to entering the outdated weight and recognized that this led to an inaccurate assessment of the resident's nutritional status. Facility policy and the RAI manual both require the use of the most recent weight within 30 days or, if unavailable, the use of a specific code with documentation, which was not followed in this case.