Incomplete Care Area Assessment Documentation for Resident
Penalty
Summary
The facility failed to complete a comprehensive Care Area Assessment (CAA) for a resident with multiple diagnoses, including traumatic brain injury, aphasia, dementia, and cognitive communication deficit. Upon review of the annual Minimum Data Set (MDS) assessment, it was found that 8 out of 9 triggered care areas lacked analysis of findings in Section V. Specifically, the MDS Coordinator did not document the nature of the resident's problems, possible causes, contributing factors, risk factors, or reasons to proceed with care planning for areas such as visual functions, communication, functional abilities, urinary incontinence and indwelling catheter, falls, nutritional status, pressure ulcer/injury, and psychotropic drug use. Staff interviews confirmed that the MDS Coordinator responsible for the assessment worked remotely and part-time, and did not provide the required information in the CAA. The DON and Administrator both stated their expectations that all CAAs be individualized and completed comprehensively, with analysis of findings for all triggered areas included before submission. The deficiency was identified through record review and staff interviews, with no documentation provided for the majority of the triggered care areas.