Inaccurate Resident Assessments Documented in MDS
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current status of three residents. For one resident with hypertension, chronic diastolic heart failure, and type II diabetes, a dental consult documented that the resident was edentulous, but the Annual Comprehensive MDS did not indicate this status in the oral and dental section. For another resident with dementia, malnutrition, and a history of stroke, a Significant Change Assessment was scheduled due to the resident signing onto hospice services, but the MDS did not reflect that the resident was receiving hospice care. In both cases, the discrepancies between the clinical records and the MDS assessments were confirmed by facility leadership during interviews. Additionally, a third resident with Alzheimer's disease and schizoaffective disorder had quarterly MDS assessments that failed to document the diagnosis of schizophrenia, despite this being present in the clinical record. The DON confirmed that the MDS assessments should have included this diagnosis. These findings demonstrate that the information recorded in the MDS assessments did not consistently match the residents' clinical records, progress notes, or observed conditions, as required by facility policy.