Inaccurate MDS Assessments for Dental Status and Mobility
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents regarding dental status and range of motion/mobility. For one resident with benign prostatic hyperplasia, chronic kidney disease, and intellectual disabilities, the admission MDS did not indicate that the resident was edentulous, despite direct observation and resident/staff interviews confirming the absence of natural teeth upon admission. Another resident with cerebral infarction, asthma, and anxiety disorder had a left-hand contracture documented in therapy records and observed during the survey, but the quarterly MDS did not reflect any upper extremity impairment. Interviews confirmed the contracture and the use of a carrot splint, which was omitted from the MDS coding. A third resident with type 2 diabetes, peripheral vascular disease, and cerebral infarction was not coded for broken natural teeth on the admission MDS, even though both observation and resident interview confirmed the presence of a broken tooth and possible cavities. In each case, the MDS Registered Nurse acknowledged that the MDS assessments were not accurately completed, resulting in discrepancies between the residents' actual conditions and the documented assessments.