Incomplete MDS Assessment for Resident Preferences
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for a resident upon admission, as required by federal guidelines. Specifically, the section of the MDS related to Preferences for Customary Routine and Activities (Section F) was either left blank or marked as 'Not Assessed.' There was no evidence in the resident's medical record that an evaluation of their daily routine or activity preferences was conducted during the assessment reference date (ARD) period. The resident in question had multiple medical conditions, including heart failure, dementia, and a history of stroke/transient ischemic attack, and was admitted from an acute care hospital. Interviews with the resident's family member revealed that they had not been consulted regarding the resident's activity preferences, and the resident had not participated in activities or left her bed. The registered nurse responsible for MDS completion confirmed that sections of the MDS were left incomplete and acknowledged that staff should have performed the necessary assessments within the ARD period to ensure accurate coding. Facility policy requires timely and complete assessments in accordance with federal and state requirements, but this was not followed in this instance.