Inaccurate Comprehensive Assessments for Eating Status
Penalty
Summary
The facility failed to ensure that comprehensive assessments contained accurate information for two of six sampled residents. For one resident with multiple diagnoses including dysphagia, gastrostomy, and hemiplegia, physician orders specified a regular texture diet with honey-thick liquids. Certified nursing assistant (CNA) task sheets consistently documented that the resident required set-up or clean-up assistance with eating, and interviews with staff confirmed the resident was able to feed himself. However, Minimum Data Set (MDS) assessments incorrectly coded the resident as 'not applicable' for eating, indicating the resident was not eating at all. The MDS Coordinator acknowledged this was an error and that the resident was able to feed himself at the time of the assessments. For another resident with diagnoses including dysphagia, adult failure to thrive, and dementia, CNA task sheets documented that the resident required partial to total assistance with eating. Observations and staff interviews confirmed that the resident required total assistance for all activities of daily living, including eating, and was unable to feed herself. Despite this, quarterly MDS assessments inaccurately documented the resident as only requiring set-up or clean-up assistance with eating. Both the LPN/MDS Coordinator and the RN/MDS Director confirmed that the eating status documented in the assessments was not accurate and did not reflect the resident's actual needs.