Inaccurate MDS Assessment of Resident's Cognitive and Communication Status
Penalty
Summary
The facility failed to ensure the accuracy of a resident's Minimum Data Set (MDS) assessment, resulting in documentation that did not reflect the resident's true cognitive and communication abilities. The resident, who had a history of mouth and throat cancer with a tracheostomy and absence of larynx, was documented in the most recent MDS as nonverbal and severely cognitively impaired. However, multiple observations and interviews revealed that the resident was able to communicate effectively using a speaking valve and was cognitively intact, as confirmed by staff, the resident's significant other, and the resident themselves. The care plan and MDS documentation did not include the resident's use of a speaking valve, and the cognitive assessment was not updated quarterly as required. Staff interviews indicated that the social worker typically carried over the initial cognitive assessment without reassessment, and the MDS coordinator was unaware that the resident's cognition had not been reassessed since admission. The business office notary relied on the inaccurate MDS cognitive score to deny notary services, believing the resident was significantly cognitively compromised. Further, the MDS coordinator and other staff relied on previous documentation and care plans, which perpetuated the inaccuracies in the resident's assessment. The speech language pathologist and other staff confirmed the resident's cognitive abilities and communication skills, but these were not reflected in the official assessments. The lack of accurate and updated assessments led to a misrepresentation of the resident's status in facility records.