Inaccurate MDS Assessments for Nutrition and Diet
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents in relation to their nutritional status. For one resident, a significant weight loss of 10.13% over six months was documented in the medical record and noted by the registered dietician, who had identified the resident as at risk for malnutrition and weight loss. Despite this, the quarterly MDS assessment did not reflect the weight loss in Section K0300. The MDS Coordinator acknowledged that the section was coded incorrectly and confirmed the resident had experienced weight loss during the specified period. For another resident, physician orders indicated the use of nutritional supplements and a fortified, mechanical soft diet due to dementia with behavioral disturbance. However, the quarterly MDS assessment did not document the therapeutic diet under the relevant section. The resident's dietary profile confirmed the use of supplements and fortified foods, and the MDS Coordinator admitted that the therapeutic diet should have been marked as present in the assessment.