Failure to Accurately Document Resident Weight Loss on MDS
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's weight loss on the Minimum Data Set (MDS) as required by facility policy. Specifically, a resident with diagnoses including Parkinson's disease, dementia, type 2 diabetes mellitus, and dysphagia experienced a significant weight loss, dropping from 163 pounds to 149 pounds within a month, which equates to an 8.59% loss. Over a six-month period, the resident lost 19% of their body weight. However, the MDS did not reflect this weight loss, incorrectly indicating that the resident had not lost 5% or more in the last month or 10% or more in the last six months. During interviews, the MDS nurse acknowledged that the MDS was inaccurate and should have documented the resident's weight loss. The DON also confirmed that the MDS should accurately reflect weight loss to enable the development of an appropriate care plan and to monitor trends. Facility policy requires that all information recorded in the MDS must reflect the resident's status at the time of the assessment, but this was not followed in this case.