Inaccurate and Overdue MDS Assessment Documentation
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment for a resident was accurately documented and completed in a timely manner. Specifically, the resident's middle initial was incorrectly entered in the section intended for the first name, and the middle initial field was left blank. This error was identified during a review of the resident's records and confirmed by the MDS Nurse, who acknowledged responsibility for providing accurate assessments. The MDS for this resident was also found to be 120 days overdue. The resident involved had a medical history including rheumatoid arthritis, diabetes, and a right artificial hip joint. The MDS indicated the resident was able to express ideas and understand others clearly, and required supervision or assistance with certain activities of daily living such as toileting, showering, and dressing. Facility policies reviewed stated that documentation must be complete and accurate, and that MDS coding should reflect an accurate assessment of each resident's functional capacity and health status.