Inaccurate MDS Dental Assessment Due to Lack of Coordination
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of dental for one resident. The resident was admitted to the facility and had a significant change MDS assessment completed, which indicated that the dental status was unable to be examined. The MDS Coordinator responsible for this assessment was working remotely at the time and was no longer employed by the company, making them unavailable for follow-up. Interviews with the Administrator and Director of Nursing (DON) revealed that the remote MDS Coordinator did not reach out to nursing staff or the DON to request a dental assessment during the lookback period, and a review of nursing documentation confirmed that no dental assessment was completed at that time. Both the Administrator and DON stated that they expected the dental status to be accurately completed on the MDS assessment.