Failure to Accurately Document Diagnoses and Treatments in MDS Assessment
Penalty
Summary
The facility failed to ensure an accurate assessment in the Minimum Data Set (MDS) for one resident. The resident was admitted with multiple diagnoses, including heart failure, cellulitis, muscle weakness, morbid obesity, hypertension, and obstructive sleep apnea (OSA). The resident's hospital history and physical also documented hypercapnic respiratory failure secondary to Obesity Hypoventilation Syndrome and OSA, which was treated with BiPAP therapy. However, upon review of the resident's MDS, it was found that the diagnosis of OSA was not included in Section I - Active Diagnoses, and the use of BiPAP was not documented in Section O - Special Treatments, Procedures, and Programs. During an interview and record review, the Assistant Director of Nursing (ADON) confirmed that both the OSA diagnosis and BiPAP treatment were missed in the MDS assessment. The facility's policy and procedures require that comprehensive assessments reflect information from progress notes, care plans, and resident observations/interviews, but this was not followed in this case. This omission had the potential to affect the resident's plan of care and delivery of services.