Inaccurate MDS Assessment of Resident Behaviors
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for one resident. The MDS assessment did not reflect the resident's behavioral symptoms during the 7-day look-back period, despite multiple documented incidents in the medical record and progress notes. The resident, who had diagnoses including non-Alzheimer's dementia and was on antipsychotic medication, exhibited behaviors such as yelling, calling out, being uncooperative with care, and attempting to hit staff. These behaviors were documented in progress notes and care plans, and the resident received medications such as Ativan and Haldol in response to these behaviors. Despite these documented behaviors, the MDS assessment indicated that the resident exhibited no behaviors during the look-back period. The MDS Coordinator later acknowledged that the assessment should have included the resident's behaviors. The RAI Manual specifies that accurate identification and coding of behavioral symptoms are essential, requiring review of records, staff interviews, and observation, none of which were adequately reflected in the MDS coding for this resident.