Failure to Accurately Document Hospice Status on MDS Assessment
Penalty
Summary
The facility failed to conduct an accurate assessment for one resident who was receiving hospice care. Review of the resident's records showed that the most recent Minimum Data Set (MDS) did not indicate the resident's hospice status, despite documentation in the care plan and physician orders confirming active hospice care. The resident's face sheet, care plan, and physician orders all reflected hospice admission and ongoing services, and observation confirmed the presence of hospice equipment in the resident's room. However, the MDS assessment omitted this information in Section O, which is designated for special treatments and services. Interviews with facility staff revealed that the MDS coordinator responsible for completing the assessment had only recently started in the role and admitted to forgetting to mark the hospice care box on the MDS. The Director of Nursing (DON) and the administrator both acknowledged that the MDS should have accurately reflected all current care and services, including hospice care, and that the omission was due to oversight and miscommunication within the nursing leadership. The DON confirmed that there was no specific policy for MDS completion beyond following the RAI guidelines.