Inaccurate MDS Assessment of Resident Behaviors
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) 3.0 assessment accurately reflected a resident's status at the time of assessment. Specifically, the MDS documented that the resident had no behaviors, despite Certified Nurse Aide (CNA) documentation and nursing progress notes indicating multiple physically aggressive behaviors, such as kicking and hitting, during the assessment period. The resident in question had diagnoses including dementia, encephalopathy, and Parkinson's disease, and was noted to have severely impaired cognition. The MDS Coordinator confirmed that the assessment was completed using a 7-day look-back period, during which CNA documentation showed conflicting entries for the same day—one indicating no behaviors and another documenting aggressive behavior. The oversight occurred when the MDS Coordinator failed to capture the documented behaviors in the MDS, resulting in an inaccurate assessment. This discrepancy was identified during the survey through record review and staff interviews.