Inaccurate MDS Assessment for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident. Record reviews showed inconsistencies between the resident's documented cognitive status and the information coded on two separate MDS assessments. The resident had diagnoses including alcohol use disorder with memory deficits and Alzheimer's disease, with progress notes indicating partial impairment regarding time and mild-to-moderate memory deficits. However, the MDS assessments reflected varying BIMS scores and descriptions of the resident's understanding, with one assessment indicating moderately impaired cognition and another indicating intact cognition, despite no acute change in mental status being documented. Interviews with facility staff revealed further discrepancies. The MDS Coordinator stated that both MDS assessments were correct due to changes in the resident over time but also indicated she was not responsible for the accuracy of the MDS. The Social Services Director, however, acknowledged that one of the MDS assessments was coded incorrectly and contradicted the resident's record, confirming that the resident's ability to understand was not accurately reflected. These actions and inactions led to the deficiency in ensuring an accurate and comprehensive assessment for the resident.