Failure to Accurately Assess and Code Resident Behaviors on MDS
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected his behavioral status. The quarterly Minimum Data Set (MDS) for the resident did not code for any behavioral symptoms, such as yelling, cursing, or verbal abuse, despite multiple documented incidents in the nurse's notes. These notes described repeated episodes where the resident shouted profanities, was verbally abusive toward staff and family members, and exhibited resistance to care. The care plan also identified the resident as being resistive to care and refusing care at times. Interviews with various staff members, including social workers, nurses, and CNAs, confirmed that the resident frequently displayed behaviors such as yelling, cursing, and making delusional statements about animals in his room. Staff consistently reported these behaviors, and the documentation in the nurse's notes supported their accounts. However, the staff member responsible for completing the MDS did not observe these behaviors during her assessment and did not review the nurse's notes or consult with other staff before coding the MDS. The facility's policy requires that all disciplines follow the guidelines in the RAI Manual and use a comprehensive assessment process, including reviewing nurse's notes and CNA documentation. The failure to accurately code the resident's behaviors on the MDS was due to the assessor not consulting available documentation or other staff, resulting in an incomplete and inaccurate assessment of the resident's behavioral needs.