Failure to Accurately Complete MDS Assessment for Significant Weight Loss
Penalty
Summary
A comprehensive Minimum Data Set (MDS) assessment was not completed accurately for one resident following their re-admission to the facility. The resident's admission MDS, with an Assessment Reference Date (ARD) of 02/19/25, indicated no cognitive impairment and did not document any weight loss in the nutrition section. However, review of the resident's progress notes written by the registered dietician on two separate occasions prior to the ARD showed significant weight loss over 30, 90, and 180 days, meeting the criteria for significant weight loss. During interviews, the MDS coordinator stated that weight change information is typically obtained through morning and weekly risk meetings, as well as daily review of the 24-hour report and physician orders. When presented with the findings, the MDS coordinator acknowledged being unaware of the significant weight loss and agreed it should have been documented on the MDS assessment. The Director of Nursing confirmed the expectation that staff should be knowledgeable about the MDS process and complete assessments accurately. The RAI Manual was referenced, emphasizing the need for accurate validation of resident status during the observation period.