Failure to Accurately Document Hospice Care in MDS Assessment
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 accurately document a resident's hospice care status in the Minimum Data Set (MDS) assessments. A resident admitted with diagnoses including acute respiratory failure, dementia, and anxiety began receiving hospice care prior to the completion of both a Significant Change MDS and a Quarterly MDS. However, review of these assessments showed that hospice care was not coded in section O as required. The MDS nurse confirmed during interview that hospice care should have been indicated in section O, and acknowledged that it was not documented for this resident in either assessment. Both the DON and the Administrator stated their expectation that MDS records should accurately reflect each resident's care status.