Inaccurate MDS Assessments and Incomplete Documentation
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for three residents, resulting in deficiencies in the documentation of active diagnoses, cognitive patterns, mood, and fall history. For one resident, the medical record showed a diagnosis of severe depression and a prescription for Lexapro, but the MDS assessment did not reflect depression as an active diagnosis. The MDS Coordinator confirmed that the diagnosis should have been documented as present during the assessment period, but it was incorrectly marked as absent. Two other residents had their Quarterly MDS assessments completed without proper evaluation of cognition and mood. The relevant sections of the MDS were left unassessed, with responses marked as dashes or 'Not assessed.' Staff interviews revealed that one resident exhibited behaviors such as refusal of care, screaming, and yelling, but these were not captured in the MDS due to the absence of a social worker during the assessment period. The MDS Registered Nurse reported that interviews required for these sections could not be conducted after the assessment reference date, resulting in incomplete documentation. Additionally, the review of one resident's MDS history showed discrepancies in the reporting of falls. Incident reports indicated that the resident had experienced multiple falls, but these were not coded on the corresponding MDS assessments. The MDS assessments failed to accurately reflect the resident's fall history, despite documentation of the incidents in the facility's records.
Plan Of Correction
F641 – Accuracy of Assessments Element #1: The MDS Coordinator reviewed and corrected inaccuracies in the submitted MDS for R9, R11, and R40. Corrections were submitted to CMS as needed. R9, 11, and 40 were assessed by the Director of Nursing and/or designee to ensure no lasting effects related to inaccurate assessment. Element #2: A 100% audit of MDS assessments completed in the last 30 days was initiated by the MDS Coordinator and designee team to identify and correct any additional inaccuracies. Element #3: The Administrator reviewed the policy on Conducting an Accurate Resident Assessment and revised as necessary. Education was provided to the Licensed Nurses and Department Managers on the policy and procedure for completion of accurate assessments. Element #4: The MDS Coordinator and/or designee will randomly review 3 assessments per week for 12 weeks for accuracy and documentation verification. All discrepancies will be logged and assessments modified to ensure accuracy. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025