Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy and completeness of Minimum Data Set (MDS) assessments for five residents, resulting in the transmission of inaccurate data to CMS and the potential for unmet care needs. For one resident with end stage renal disease and dependence on hemodialysis, the MDS did not accurately reflect the resident's therapeutic diet or the presence of a Permacath for dialysis, despite clear documentation in the medical record and direct observation. The MDS nurse acknowledged these inaccuracies and confirmed that the assessment should have included these details, as the MDS guides the resident's care plan. Another resident with chronic obstructive pulmonary disease, diabetes, and depression was assessed in the MDS as preferring English and not needing an interpreter, even though the resident primarily spoke Cantonese and used a communication board with Cantonese translations. Interviews with the resident, family, and staff revealed that the resident preferred Cantonese and had difficulty communicating in English, but this was not verified or accurately documented in the MDS. Similarly, a resident whose preferred language was Korean was documented in the MDS as not needing an interpreter, but interviews revealed that staff communicated with the resident in English or Spanish, which the resident did not understand well, and no interpreter or translation services were used. Additional deficiencies were found in the assessment of oral and dental status. One resident was documented in the MDS as having no oral or dental issues, despite not having natural teeth and using dentures, which the resident reported as loose and difficult to use during meals. Another resident was also incorrectly assessed as having no dental issues, even though observation confirmed the absence of natural teeth. The facility's policies required comprehensive and accurate assessments, including direct observation and communication with residents, but these were not followed, leading to inaccurate MDS documentation.