Inaccurate MDS Assessment Documentation for Dental Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately documented for a resident reviewed for dental care. Observations showed that the resident was edentulous and wore complete dentures, which were not present at the time of observation. The nursing admission assessment confirmed the absence of natural teeth. However, the MDS assessment incorrectly indicated that the resident had natural teeth, contradicting both the resident's statement and the nursing assessment. Interviews with staff further confirmed that the resident had no natural teeth, and the MDS Coordinator acknowledged the documentation error in the MDS assessment. Additionally, the MDS assessment's signature page listed sections as being completed by a staff member identified as a Social Worker, when in fact this individual was a Social Services Assistant. This misidentification was confirmed by both the Social Services Director and the MDS Coordinator, who recognized the inaccurate information on the MDS assessment's signature page.