Inaccurate MDS Assessment of Tobacco Use
Penalty
Summary
The facility failed to ensure that a resident assessment accurately reflected the resident's status for one of ten residents reviewed. Specifically, a significant change Minimum Data Set (MDS) assessment for a resident was incorrectly documented, indicating that the resident did not use tobacco. However, a review of the resident's face sheet and smoking safety screen showed that the resident was an unsafe smoker. The MDS nurse responsible for completing the assessment confirmed during an interview that the resident was a smoker and acknowledged the error in coding the MDS. The resident involved had multiple diagnoses, including hepatic encephalopathy, schizophrenia, type 2 diabetes mellitus, hyperlipidemia, and bipolar disorder. The MDS nurse stated she used the Resident Assessment Instrument (RAI) as a reference and had electronic access to it, but could not explain why the resident was not coded as a smoker. The RAI manual specifies that tobacco use should be coded as 'yes' if there is any indication of tobacco use during the look-back period, which was not followed in this case.