Inaccurate MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident who was receiving hospice care. The resident, who had diagnoses including atherosclerotic heart disease, moderate protein-calorie malnutrition, paroxysmal atrial fibrillation, and was under palliative care, was observed in bed with a hospice nurse present. Review of the clinical record confirmed the resident had been on hospice services since a specified date and remained on hospice at the time of the survey. However, while previous MDS assessments correctly identified the resident as receiving hospice care, a subsequent quarterly MDS assessment inaccurately documented that the resident was not on hospice care. During interviews, the DON identified the staff responsible for MDS assessments and acknowledged the concern regarding the inaccurate documentation. The facility did not have a specific policy addressing MDS accuracy and instead referred to the RAI Manual for guidance. The deficiency was identified through record review and staff interviews, which confirmed the inconsistency in the MDS documentation for a resident on hospice services.