Inaccurate MDS Assessment of Resident's Hearing Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's hearing status. Specifically, for one resident with a history of hearing loss and use of hearing aids, the MDS assessments repeatedly documented her hearing as adequate and indicated no use of hearing aids. This was inconsistent with the resident's own statements, staff interviews, and direct observations, all of which confirmed significant hearing impairment and the absence of hearing aids. The resident reported difficulty hearing, the need for others to speak loudly, and the loss of her hearing aids, which she had upon admission. Staff interviews corroborated that the resident had trouble hearing and that hearing aids were not present or in use. Record reviews showed no documentation in the care plan or physician's orders regarding hearing aids, and the MDS nurse acknowledged that the assessments were inaccurate. The social worker and nursing staff were unaware of the resident's hearing issues, and the MDS nurse confirmed that the coding for hearing status was incorrect on multiple assessments. The facility's policy requires that assessments accurately reflect the resident's status, but this was not followed in this case, resulting in inaccurate documentation of the resident's hearing ability.