Inaccurate MDS Assessment for Cognition and Behaviors
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for a resident with dementia and cognitive impairment. Record reviews showed inconsistencies in the MDS documentation regarding the resident's ability to understand and be understood, as well as their cognitive skills for daily decision making. For example, different MDS assessments alternately indicated the resident was rarely understood, usually understood, or had a BIMS score indicating moderate impairment, while progress notes and interviews described the resident as unable to provide meaningful history or answer questions. The MDS Coordinator acknowledged that the MDS was coded incorrectly for communication abilities and that discrepancies existed between the MDS and the resident's record. Additionally, the MDS failed to accurately reflect the resident's behavioral symptoms. While the annual MDS indicated no behaviors, progress notes documented frequent episodes of yelling, cursing, and disruptive behavior over several dates. The Dementia Program Director confirmed that the resident exhibited behaviors weekly, and the MDS Coordinator stated that the MDS should have indicated the presence of behaviors, as staff had recorded such incidents almost every other day. The MDS Coordinator also noted that staff responsible for completing the MDS did not follow up on discrepancies, resulting in an inaccurate representation of the resident's condition.