Failure to Accurately Document Resident Assessments in MDS
Penalty
Summary
The facility failed to accurately assess and document the status of two residents during their quarterly Minimum Data Set (MDS) assessments. For one resident, the facility did not document lower extremity impairment, despite multiple sources of information indicating the presence of bilateral lower extremity contractures since admission. Observations showed the resident was bedbound with contracted knees, and both the admitting nurse and wound care nurse confirmed the contractures were present upon admission and had not changed. The resident's MDS, however, indicated no upper or lower extremity impairment, which was inconsistent with the resident's actual condition and care needs. For another resident, the facility failed to document the use of corrective lenses in the quarterly MDS. The resident's care plan noted impaired vision and the use of glasses due to glaucoma, and observations confirmed the resident wore glasses while reading. Despite this, the MDS stated the resident had impaired vision but did not use corrective lenses. The MDS nurse acknowledged that the resident wore glasses and that this should have been documented in the MDS and care plan. Interviews with facility staff, including the MDS nurse and DON, confirmed that the assessments were inaccurate and did not reflect the residents' actual conditions. The facility's policy requires that qualified staff conduct accurate assessments reflective of the resident's status at the time of assessment, but this was not followed in these cases. The failure to document these conditions in the MDS could result in an inaccurate description of the residents and their care needs.