Inaccurate Resident Assessments Documented
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for two residents. For one resident, the admission assessment indicated moderate cognitive impairment and no unhealed pressure ulcers or deep tissue injuries upon admission. However, the discharge assessment later documented the presence of one unstageable pressure ulcer and two unstageable deep tissue injuries as being present upon admission or reentry, which was inconsistent with the initial assessment. For another resident, the admission assessment documented that the resident was not edentulous, despite observations and interviews confirming the resident had no natural teeth and did not have dentures. The quarterly assessment also failed to note the resident's difficulty chewing, which was reported by both the resident and a family representative. Both the DON and the MDS coordinator acknowledged that the assessments were inaccurate regarding the resident's dental status and the presence of pressure injuries.