Inaccurate Resident Assessments for Oral/Dental Status and Falls
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the oral/dental status and fall history for several residents. Specifically, multiple Minimum Data Set (MDS) assessments for five residents did not correctly indicate the presence of dentures or the absence of natural teeth, despite direct observations, interviews, and progress notes confirming denture use. For example, one resident was observed wearing ill-fitted upper dentures, and both the resident's family member and facility staff confirmed the use of dentures, yet the MDS assessments marked 'none of the above' for oral/dental status. Similar discrepancies were found for other residents, where care plans and MDS assessments did not document denture use, even though progress notes and resident interviews confirmed it. Additionally, the facility failed to accurately code a fall for another resident on the MDS assessment. Nursing progress notes documented an incident where the resident slid from a chair to the floor, resulting in a hematoma, but the corresponding MDS assessment did not reflect a fall during the look-back period. Interviews with the MDS Coordinator, DON, and nursing staff confirmed that such an event should have been coded as a fall and included in the assessment. Staff acknowledged the importance of accurate documentation for care planning and funding, and recognized that the omission was inconsistent with facility policy and regulatory requirements. Facility policy and federal regulations require that assessments accurately reflect the resident's status, including direct observation and communication with residents and staff. The findings showed that qualified staff did not consistently document medical and functional problems, such as denture use and falls, in the MDS and care plans. This resulted in assessments that did not accurately represent the residents' conditions at the time of assessment, as required by both facility policy and federal guidelines.