Inaccurate Resident Assessments Documented in MDS
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current status of several residents, as evidenced by discrepancies between physician orders, weight records, and Minimum Data Set (MDS) documentation. For three residents reviewed for nutrition, the MDS assessments did not indicate the correct diet texture or recent weight loss, despite physician orders and weight summaries showing otherwise. Specifically, one resident with a physician order for a pureed diet was not documented as having a mechanically altered diet in the MDS, and another with a mechanical soft diet order was similarly not reflected in the MDS. Additionally, a resident who experienced a 5.1% weight loss over a month was not identified as having significant weight loss in the MDS assessment. For a resident reviewed for hospice services, the admission MDS assessment failed to indicate that the resident was under hospice care, despite a physician order for hospice admission. Interviews with facility staff, including the MDS Coordinator RN and an LPN, confirmed that these sections of the MDS were incorrectly documented and would require correction. The facility's policy states that the Resident Assessment Coordinator is responsible for ensuring timely and accurate assessments, but these requirements were not met in the cases reviewed.