Inaccurate MDS Assessments Due to Documentation Discrepancies
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected a resident's status, resulting in discrepancies across multiple assessment dates. Specifically, the MDS assessments for one resident showed inconsistent documentation regarding extremity impairments, use of assistive devices, and functional abilities. For example, some assessments indicated impairment in upper and/or lower extremities and the use of a wheelchair or walker, while others documented no impairments and no assistive device use, despite the resident consistently using a wheelchair. The resident involved had diagnoses including vascular dementia, cardiomyopathy, and a mood disorder, and was noted to have varying levels of cognitive impairment and functional dependency in the MDS records. The inconsistencies were found in assessments completed by different staff members, including the Regional Director and the Director of Rehabilitation, who admitted to errors in coding the resident's use of assistive devices and functional status. The MDS Coordinator acknowledged that the information in several assessments was incorrect and that the resident's use of a wheelchair had not changed. Interviews revealed that the MDS Coordinator oversees the completion of the MDS but relies on each department to complete and sign off on their respective sections. The Coordinator stated that it was unrealistic to review all areas of the assessment and that the discrepancies should have been identified, especially when the same person completed multiple sections. The Director of Rehabilitation also confirmed an error in coding the resident's device use, further contributing to the inaccurate assessments.