Inaccurate and Incomplete MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for two of twelve sampled residents. For one resident with cognitive communication deficit and major depressive disorder, the MDS assessment was found to be incomplete, specifically missing information in Sections C (Brief Interview for Mental Status) and D (Mood assessment/interview). Another resident, diagnosed with dementia and nontraumatic intracranial hemorrhage, was receiving hospice services per physician order, but the MDS assessment did not document that hospice services were in place, inaccurately reflecting the resident's care status. These inaccuracies were confirmed by the Registered Nurse Assessment Coordinator during staff interview. The deficiencies were identified through clinical record review and staff interview, with direct evidence of incomplete or inaccurate documentation in the residents' MDS assessments.