Incomplete Care Area Assessments in Resident MDS Documentation
Penalty
Summary
The facility failed to ensure that a resident's Admission Minimum Data Set (MDS) included fully developed Care Area Assessments (CAAs). Record review and interviews revealed that the CAAs for functional abilities (self-care mobility), urinary incontinence and indwelling catheter, pain, and pressure ulcer/injury lacked analysis or further development. The resident in question had a complex medical history, including multiple sclerosis, diabetes mellitus, edema, hypokalemia, COPD, muscle weakness, overactive bladder, urinary retention, anxiety, dementia, behavioral disturbance, hypertension, major depressive disorder, and obesity. During an interview, the administrative nurse confirmed that all CAAs should include analysis of findings and that this documentation flows into the plan of care. The absence of analysis in the CAAs could result in unidentified care needs for the resident. Additionally, the facility was unable to provide a policy regarding the development of MDS or CAAs.