Incomplete MDS Assessment for Resident Preferences
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for one resident by not filling out Section F, which addresses preferences for customary routines and activities. The resident in question had memory problems but no delusions, hallucinations, or rejection of care, as indicated in the annual MDS. During the assessment process, the MDS coordinator stated that the life enrichment coordinator was responsible for completing the activity review and preferences assessment, but this information was not entered into Section F. The facility's policy requires a registered nurse to coordinate and certify the accuracy of each resident's MDS assessment, and each individual completing a portion of the assessment must certify its accuracy. However, the required section was left incomplete, resulting in an inaccurate assessment.