Inaccurate MDS Assessment Documentation Following Choking Incident
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected a resident's clinical status. A resident with a history of cerebrovascular accident and dysphagia was admitted and subsequently experienced a choking incident during a meal, which required the Heimlich maneuver and resulted in a downgrade of the resident's diet to mechanical soft, and later to pureed with nectar consistency due to aspiration pneumonia. Despite these significant changes in the resident's condition and dietary orders, the MDS assessments did not accurately document the resident's need for a mechanically altered diet or the occurrence of coughing or choking during meals. Specifically, the Discharge Return Anticipated MDS did not indicate the resident was on a mechanically altered diet, and the Medicare 5-Day End of Part A Stay MDS failed to note the resident's coughing or choking episodes, even though these events were documented in the medical record and incident reports. These omissions were confirmed by the staff member responsible for MDS completion, who acknowledged that the assessments should have reflected the resident's actual status at the time.