Inaccurate MDS Assessments for Vision and Transfer Assistance
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for three residents, resulting in deficiencies related to the documentation of vision status and transfer assistance. For one resident with a history of hyperglycemia, repeated falls, and documented diagnoses of cataracts and macular degeneration, the MDS inaccurately indicated adequate vision and no use of corrective lenses, despite multiple clinical notes and resident statements confirming significant vision impairment and the need for cataract surgery. The MDS coordinator and DON acknowledged awareness of the resident's vision issues, but the assessment did not reflect the actual condition. For two other residents, both with significant medical histories and preferences to remain in bed, the facility failed to accurately code the level of assistance provided for transfers. Despite CNA charting indicating dependent assistance for transfers out of bed to wheelchair, interviews with CNAs, the MDS nurse, and the DON confirmed that these residents had not been transferred out of bed for months, and the documentation should have reflected that transfers were not applicable. The inaccurate CNA documentation led to incorrect MDS coding for both residents. Staff interviews revealed a lack of adherence to the Resident Assessment Instrument (RAI) manual guidelines, with CNA documentation based on hypothetical assistance rather than actual care provided. The MDS nurse and DON both stated that MDS assessments should be based on actual assistance provided and current resident status, but the failure to ensure accurate documentation and assessment resulted in the deficiencies identified during the survey.