Failure to Accurately Complete BIMS Assessment on MDS
Penalty
Summary
The facility failed to complete accurate assessments for a resident regarding the Brief Interview of Mental Status (BIMS) as part of the federally mandated Minimum Data Set (MDS) process. Medical record review showed that upon admission, the resident was identified as their own representative and was able to sign the admission contract. The social worker completed a BIMS assessment at admission, with the resident scoring a 13, indicating cognitive intactness. However, subsequent reviews of the resident's medical record revealed that all submitted MDS assessments for cognitive status since admission did not include the BIMS score, and the section was either not assessed or not rated as required. During an interview, the social worker responsible for completing the BIMS and MDS assessments was unable to recall the details and needed to review her notes. Upon follow-up, the social worker acknowledged an error in documentation, stating that another resident's information was entered under this resident, resulting in inaccurate MDS submissions for the BIMS section. This documentation error led to the failure to ensure an accurate assessment of the resident's cognitive status.