Incomplete and Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were accurate and fully completed for four out of eight residents reviewed. According to the Resident Assessment Instrument (RAI) User's Manual, specific sections of the MDS, including Section C: Cognitive Patterns and Section D: Mood, require completion based on the resident's ability to be understood. For several residents, documentation indicated that they were not in a persistent vegetative state and were at least sometimes understood, which should have triggered the completion of the Brief Interview for Mental Status (BIMS) and Resident Mood Interview. However, these sections were marked as 'Not Assessed' for the affected residents. Review of clinical records showed that for each of the four residents, key assessment sections were either left incomplete or not assessed at all, despite documentation that indicated the assessments should have been conducted. This included residents who were documented as being understood or usually understood, yet their cognitive and mood assessments were not performed as required. The Nursing Home Administrator confirmed during an interview that the facility did not ensure the comprehensive MDS assessments were accurate and fully completed for these residents.