Inaccurate MDS Assessments for Weight and Constipation
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents, specifically regarding weights and constipation status. For one resident, the weight recorded in the MDS did not match the most current weight documented in the resident's weight record during the look-back period. Similarly, another resident's MDS weight entry was inconsistent with the actual weight recorded in the facility's records. In both cases, staff interviews confirmed that the weights entered into the MDS were inaccurate and should have reflected the most recent documented weights. Additionally, the facility did not accurately code constipation for a resident who had only two bowel movements during the seven-day look-back period, as defined by the RAI manual. The staff responsible for coding relied on the presence of hard stools rather than the frequency of bowel movements, resulting in the omission of constipation in the MDS assessment. Interviews with staff confirmed that the MDS should have indicated constipation based on the documented bowel movement frequency.