Inaccurate MDS Assessment of Hearing and Discharge Status
Penalty
Summary
The facility failed to accurately encode assessment information on the Minimum Data Set (MDS) for two residents, resulting in inaccurate documentation of hearing capability and discharge status. For one resident, the MDS did not reflect the resident's significant hearing impairment, despite multiple observations and interviews indicating the resident had difficulty hearing, did not possess a hearing aid, and expressed a desire for one. Certified Nurse Assistants reported needing to speak loudly, slowly, and directly in front of the resident, and the resident confirmed reading lips and being hard of hearing. However, the MDS Coordinator stated that the resident did not complain of hearing difficulty at the time of assessment, leading to the omission of this need in the MDS. For another resident, the discharge status was incorrectly coded on the MDS as a transfer to a general acute care hospital, when in fact the resident was discharged to a skilled nursing facility (SNF) for continued long-term care. Multiple records, including progress notes, order summaries, and discharge summaries, consistently documented the transfer to a SNF. During a review, the MDS nurse acknowledged the error and confirmed that the MDS should have been coded to reflect discharge to a SNF. The facility's policies and procedures require accurate and comprehensive resident assessments in accordance with federal and state regulations. The inaccuracies in the MDS assessments for both residents were contrary to these policies and had the potential to negatively affect the quality of care and services provided.