Incomplete MDS and CAA Documentation for Resident with Dementia
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to complete a thorough Minimum Data Set (MDS) assessment for one resident with a diagnosis of dementia and moderately impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of nine. The resident was frequently incontinent of bowel and bladder and required staff assistance for toileting. The Care Area Assessments (CAA) triggered by the MDS were not fully analyzed, as the analysis of findings was missing from the documentation. This incomplete assessment was confirmed through review of the resident's electronic medical record and interviews with facility staff, who acknowledged the expectation to thoroughly complete the MDS and associated CAAs according to the RAI manual.