Inaccurate MDS Assessments Due to Language and Documentation Failures
Penalty
Summary
The facility failed to accurately complete comprehensive Minimum Data Set (MDS) assessments for two residents out of a sample of 29. For one resident, who was admitted with diagnoses including benign neoplasm of the meninges and diabetes, the facility did not conduct the Brief Interview for Mental Status (BIMS) assessment in the resident's primary language. Although the resident's care plan and clinical record indicated a language barrier and the need for translation services, the social worker responsible for the assessment did not utilize available translation resources, such as bilingual staff, family members, or telephone translation services. Interviews confirmed that translation services were available and that the resident was able to communicate effectively in their primary language when such services were used, but the assessment was not attempted in the appropriate language, leading to an inaccurate evaluation of the resident's mental status. For the second resident, who was admitted with cervical spinal stenosis and had recently undergone a cervical discectomy and fusion, the facility failed to accurately code the presence of a surgical wound on the MDS assessment. Hospital discharge documentation and care instructions clearly indicated the presence of a surgical incision and dressing on the anterior neck. Observations and interviews with facility staff confirmed that the resident was admitted with a surgical wound, but the MDS assessment did not reflect this, as the surgical wound box was not checked and no skin issues were identified in the initial evaluation. These deficiencies were identified through record review, staff interviews, and direct observation, demonstrating that the facility did not follow established protocols and policies for accurate resident assessment, particularly in relation to language needs and the documentation of surgical wounds. The failures resulted in inaccurate MDS assessments for both residents.