Failure to Accurately Assess and Document Resident Needs
Penalty
Summary
The facility failed to ensure accurate and comprehensive assessments for two residents, resulting in deficiencies related to both hearing and mental health diagnoses. For one resident, the Admission Record indicated a diagnosis of schizophrenia, but the Minimum Data Set (MDS) assessments were inconsistently coded. The Admission MDS did not list schizophrenia as an active diagnosis, while subsequent Quarterly MDSs did, despite the resident being in a persistent vegetative state and lacking documentation to support an active diagnosis according to DSM-5 criteria. The MDS Coordinator acknowledged that the Quarterly MDSs were incorrectly coded, as the resident's condition did not meet the criteria for schizophrenia, and the diagnosis was carried over from the hospital without sufficient supporting documentation. Another resident was admitted with multiple diagnoses, including diabetes, heart failure, acute kidney failure, and depression. The MDS assessment indicated the resident had adequate hearing, but the Social Service Hearing Assessment noted impaired hearing and did not recommend hearing appliances or consultation. The resident reported significant difficulty hearing and a prolonged wait for hearing aids, with missed and canceled audiology appointments due to logistical issues. The Social Service Director confirmed that the assessment should have indicated a need for a hearing consultation and that a follow-up assessment was not completed as required. The MDS Coordinator also stated that the resident's hearing should have been coded as moderately impaired rather than adequate. Facility policies required staff to attest to the accuracy of MDS assessments and to assist hearing-impaired residents in obtaining necessary services. However, the assessments for both residents were not completed accurately, and required follow-up actions, such as timely hearing assessments and proper documentation of mental health diagnoses, were not performed. These failures resulted in inaccurate depictions of the residents' needs and affected their care plans.