Inaccurate MDS Assessment of Oral/Dental Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the oral and dental status of a resident. The resident, who had a history of schizophrenia, bipolar disorder, dementia, and diabetes mellitus, was assessed as not having any oral or dental issues on the MDS. However, during an observation and interview, the resident reported difficulty chewing food due to the absence of natural teeth. This discrepancy was confirmed during a review of the MDS with the MDS nurse, who acknowledged that the coding was inaccurate and did not represent the resident's actual oral and dental condition. The facility's policy required that resident assessments accurately reflect the resident's status and be certified by a registered nurse. Despite this, the MDS for the resident did not document the lack of natural teeth, resulting in incorrect data being transmitted to CMS. The MDS nurse stated that accurate coding is important for quality measures, care monitoring, outcome measurement, and care planning, and acknowledged that the inaccuracy could lead to unmet care needs and services for the resident.