Inaccurate MDS Assessments for Dental and Mental Health Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the current status of four residents. For one resident, the annual MDS assessment indicated the presence of all natural teeth without problems, despite dental records and direct observation confirming the absence of natural teeth and the presence of inflamed, swollen, and bleeding gums. This resident was observed on a pureed diet and verbally confirmed having no teeth during an interview. Another resident's annual MDS assessment also inaccurately documented the presence of all natural teeth without problems, even though the resident reported ongoing dental pain, loss of teeth, and the use of oral gel for pain relief. The resident had not communicated the specific nature of his dental pain to staff, and the nursing and MDS staff were unaware of his dental issues at the time of assessment. The resident's care plan was later updated to reflect dental concerns, but the original MDS did not capture these issues. A third resident's MDS assessment failed to document a mental illness condition, leaving the relevant section blank, despite the resident having diagnoses of bipolar disorder and schizophrenia, and a PASRR evaluation confirming serious mental illness. For a fourth resident, the MDS assessment indicated edentulism (no natural teeth), but the resident reported having several teeth remaining, and dental records supported the presence of non-restorable teeth recommended for extraction. These inaccuracies in the MDS assessments were identified through record review, observation, and interviews, and were not consistent with the residents' actual conditions as documented in other clinical records and direct statements.