Inaccurate MDS Assessments Across Multiple Domains
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for five residents, resulting in multiple inaccuracies across various assessment domains. For one resident, staff documented adequate vision and no use of corrective lenses on several MDS assessments, despite observations of the resident using eyeglasses and stating a need for them. Additionally, a chronic ulcer treated by a contracted wound company was not reflected in the MDS, even though the resident was being treated for it at the time. Another resident was incorrectly coded as not interviewable for cognitive patterns and as demonstrating delusions, despite multiple observations and staff interviews confirming the resident was able to communicate and did not exhibit delusional behavior. For a third resident, the MDS inaccurately indicated staff were unable to examine dental status, and inconsistencies were found regarding the resident's ability to communicate and primary language. Staff failed to document the need for an interpreter, even though the resident's family confirmed Samoan as the primary language and that the resident would benefit from interpretation services. Further, one resident's MDS inaccurately reported no natural teeth, while both care plans and direct observation confirmed the presence of two natural teeth, which were loose and causing chewing difficulties. Another resident's discharge MDS incorrectly documented the discharge location as a hospital, while the discharge summary indicated the resident was sent home. In each case, staff interviews confirmed the MDS assessments were completed inaccurately, leading to discrepancies between the residents' actual conditions and their documented assessments.