Inaccurate MDS Assessment and Documentation for Hospice Resident
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for a resident who was admitted to hospice care with a diagnosis of dementia. Clinical record review showed that the resident was admitted to hospice services with dementia, and the Significant Change MDS correctly indicated hospice level of care and listed dementia among active diagnoses. However, subsequent Quarterly MDS assessments did not reflect hospice services or the dementia diagnosis, and the section for special treatments, procedures, and programs was left blank. The resident's cognitive status was documented as severely impaired, but the required updates to the MDS were not made to accurately reflect the resident's current condition and services received. Interviews with facility staff revealed that there was a lack of continuity and oversight in the MDS assessment process. The MDS Coordinator position experienced turnover, and the new coordinator reported insufficient training and support, as well as outdated care plans and inaccurate MDS documentation. The facility's policy required accurate assessments by qualified staff, but this was not followed, resulting in incomplete and inaccurate resident assessments.