Incomplete MDS Assessment Components for Resident
Penalty
No penalty information released
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Summary
The facility failed to complete all required components of comprehensive assessments for one resident. Medical record review showed that a resident with multiple diagnoses, including quadriplegia, chronic pain, diabetes mellitus, neurogenic bladder, major depressive disorder, and peripheral vascular disease, was admitted to the facility. The annual Minimum Data Set (MDS) 3.0 assessment for this resident did not include the required Cognitive Pattern: Brief Interview for Mental Status and Pain Assessment interview. Additionally, the quarterly MDS assessment for the same resident was missing the required Pain Assessment interview. These omissions were confirmed during an interview with the Assistant Director of Nursing.