Incomplete MDS Assessments for Cognition and Mood
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed thoroughly for two residents, specifically in the areas of cognition and mood. For both residents, the relevant sections of the MDS—Section C (Cognitive Patterns) and Section D (Mood)—were either marked as 'Not Assessed' or left blank, with no evidence in the medical records that the required assessments, such as the Brief Interview for Mental Status (BIMS) or the Patient Health Questionnaire-9 (PHQ-9), were conducted during the assessment reference date (ARD). This lack of assessment meant that critical indicators of cognitive status and potential depressive symptoms were not evaluated as required by the Centers for Medicare and Medicaid Services (CMS) guidelines. One resident had multiple medical conditions, including high blood pressure, renal insufficiency or failure, and dementia, while the other had a history of stroke and aphasia. Despite these significant health issues, the facility did not complete the necessary cognitive and mood assessments for either resident. A registered nurse responsible for MDS completion confirmed that these sections were not filled out and acknowledged that staff had been informed this was unacceptable. The facility's policy required timely and complete assessments in accordance with federal and state guidelines, but this was not followed in these cases.