Inaccurate MDS Weight Documentation for Multiple Residents
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for three out of five sampled residents in relation to their nutritional status, specifically regarding the documentation of resident weights. According to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) guidelines, the most recent weight within 30 days of the Assessment Reference Date (ARD) should be used for MDS entries. In the case of one resident with multiple diagnoses including malnutrition and dementia, the MDS recorded a weight from a week prior to the ARD, despite a more recent weight being available on the ARD itself. The MDS Coordinator confirmed that the incorrect, earlier weight was entered instead of the most current one. For two other residents, the MDS assessments documented weights that were not obtained within the required 30-day window prior to the ARD. In one instance, the weight entered was from 41 days before the ARD, and there were no documented weights within the appropriate timeframe. The correct procedure, as outlined in the RAI manual, would have been to use the standard code for no information and document the rationale in the medical record. In the third case, the weight recorded in the MDS was from several months prior to the ARD, again not meeting the 30-day requirement. These findings were confirmed through interviews with the MDS Coordinator, who acknowledged the discrepancies.