Failure to Complete Comprehensive MDS Assessment for Cognitively Impaired Resident
Penalty
Summary
The facility failed to accurately complete a comprehensive Minimum Data Set (MDS) assessment within the required timeframe for a resident who was admitted with significant cognitive impairment and a history of being unable to make his own decisions. Hospital records prior to admission documented the resident's incompetence and need for a public fiduciary, as well as a history of cognitive impairment. Upon admission, the resident was noted to have diagnoses including malignant neoplasm of the mandible, temporomandibular joint disorder, and severe protein-calorie deficit. Facility documentation, including a speech therapy evaluation and progress notes, further confirmed the resident's cognitive impairment and poor ability to provide his own history. Despite this, the MDS admission assessment did not include a Brief Interview for Mental Status (BIMS) score, and both the cognitive patterns section and the staff assessment for mental status were left blank. Interviews with facility staff, including a CNA, LPN, and the DON, confirmed that the resident exhibited confusion and had episodes of wandering, with one incident involving the resident leaving the facility and being found a mile away. Facility policy and the RAI manual require comprehensive assessment of cognition and behavior to identify care needs and risks, but these were not completed as required for this resident.