Failure to Ensure Accurate Resident Assessments
Penalty
Summary
The facility failed to ensure that residents received accurate and comprehensive assessments, as evidenced by multiple discrepancies found during interviews and record reviews. One resident with severe bilateral hearing loss, who could only communicate via a whiteboard, was incorrectly assessed on the Minimum Data Set (MDS) as having moderate hearing loss, despite documentation and staff interviews confirming a higher level of impairment. Another resident who experienced a fall was not accurately coded for this event on the quarterly MDS assessment, even though progress notes and care plans documented the fall. A third resident with an indwelling Foley catheter was discharged to the hospital, but the discharge MDS assessment inaccurately coded urinary continence as "occasionally incontinent" instead of "Not rated," which is the correct coding when a catheter is present. Additionally, a fourth resident who had a fall and was sent to the hospital was not coded for the fall on the subsequent quarterly MDS assessment, despite clinical records confirming the incident. In each case, the discrepancies were confirmed by facility staff, including the Director of Nursing and the MDS Coordinator, during interviews with surveyors. These findings demonstrate that the facility did not consistently ensure the accuracy of MDS assessments for residents, particularly in areas related to hearing loss, falls, and urinary continence. The inaccuracies were identified through direct review of medical records, care plans, and staff interviews, highlighting a pattern of incomplete or incorrect documentation in resident assessments.