Inaccurate Documentation of Resident Assessments
Penalty
Summary
The facility failed to ensure accurate documentation of comprehensive assessments for four residents, specifically regarding diagnoses, vision, and oxygen use. For one resident, the Minimum Data Set (MDS) included a diagnosis of schizophrenia, despite no supporting documentation in the medical or psychiatric records. The MDS Registered Nurse acknowledged this discrepancy during a side-by-side review of the resident's records. Another resident's MDS assessment did not reflect the use of oxygen or impaired vision, even though physician orders, care plans, and direct observation confirmed the use of oxygen therapy and a diagnosis of legal blindness. The MDS Coordinator was informed of these inconsistencies but did not provide an immediate explanation for the discrepancies. A third resident's MDS assessment omitted a diagnosis of Post Traumatic Stress Disorder (PTSD), despite it being listed among the resident's medical diagnoses. Interviews with various staff members, including CNAs and nurses, revealed a lack of awareness or documentation regarding the resident's PTSD triggers. The MDS Coordinator confirmed that PTSD should be documented in Section I of the MDS but acknowledged the omission and noted that other MDS Coordinators were not present to address the issue. For the fourth resident, the MDS assessment indicated adequate vision and clear speech, while the care plan documented impaired communication and vision loss due to glaucoma and cataracts. Interviews with the MDS Coordinator and Social Services Director revealed conflicting assessments of the resident's vision status, with the care plan and medical history indicating impairment, but the MDS and social services staff reporting adequate vision. These inconsistencies demonstrate a failure to accurately assess and document residents' conditions in the MDS, as required.