Failure to Accurately Complete MDS Assessments for Skin, Pain, and Oral Conditions
Penalty
Summary
Facility staff failed to accurately complete Minimum Data Set (MDS) assessments for multiple residents, resulting in deficiencies in the documentation of residents' clinical conditions as of the Assessment Reference Date. For one resident with a history of pressure ulcers, the MDS was incorrectly coded to indicate that a pressure ulcer was not present on admission, despite medical records and staff interviews confirming the wound had been present since admission and had not healed. Another resident with multiple wounds, including surgical, diabetic, and vascular wounds, had these conditions omitted from the MDS assessment, even though they were documented in the medical record and observed by staff and surveyors. Pain assessments were not completed as required for two residents who were cognitively intact and able to communicate. In both cases, the MDS assessments lacked documentation of pain interviews or staff assessments, despite physician orders for pain monitoring and ongoing administration of pain medications. Staff interviews confirmed that the required pain assessments were not conducted within the appropriate timeframe, resulting in incomplete and inaccurate MDS documentation. Additionally, a resident with oral cancer, broken teeth, and ongoing mouth pain was not accurately coded in the MDS assessment regarding oral/dental status and pain, despite clear evidence in the medical record, physician orders for pain management, and resident and staff reports of ongoing oral pain and abnormal mouth tissue. These failures to accurately assess and document residents' conditions on the MDS assessments were confirmed through record reviews, staff interviews, and direct observations by surveyors.