Failure to Complete Accurate Resident Assessments and Discharge Documentation
Penalty
Summary
The facility failed to complete and document accurate resident assessments as required by its own policy and federal regulations. For one resident, who had diagnoses including adult failure to thrive and malignant neoplasms, the facility did not complete a significant change assessment upon the resident's re-admittance and transition to hospice care. Although the resident was admitted to hospice services and this was documented in physician orders and nursing notes, the quarterly Minimum Data Set (MDS) assessment did not reflect the initiation of hospice services in Section O, and no significant change assessment was completed following the resident's change in status. Additionally, for another resident with multiple diagnoses including dementia and mental health disorders, the facility failed to accurately document the discharge status. The discharge MDS indicated the resident was discharged to a hospital, while progress notes and discharge instructions showed the resident was actually discharged to a personal care home. The MDS Coordinator relied solely on census information without cross-referencing other documentation, resulting in inaccurate discharge records. Interviews with staff confirmed these documentation errors and highlighted lapses in verifying and communicating changes in resident status.