Inaccurate MDS Assessment for Resident on Mechanically Altered Diet
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident. According to the facility's policy, residents are to receive assessments that accurately reflect their status at the time of assessment, conducted by qualified staff. For this resident, who had a diagnosis of Alzheimer's disease, the quarterly MDS assessment indicated that the resident was not on a mechanically altered diet. However, a review of the resident's diet orders and communication forms showed that the resident had been placed on a mechanical soft, ground meat diet due to a mouth injury, and this order was still in effect at the time of the MDS assessment. Interviews with facility staff, including the Dietary Manager and Nurse Practitioner, confirmed that the resident was receiving a mechanically altered diet and had not been reassessed to change this order. The MDS Coordinator acknowledged that the MDS Section K should have indicated the use of a mechanically altered diet but was not marked accordingly. This discrepancy between the resident's actual diet and what was documented in the MDS assessment resulted in an inaccurate assessment for the resident.