Failure to Accurately Document Resident Behaviors and Care Rejection in MDS
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to accurately document a resident's verbal and physical abuse towards staff and repeated rejection of care in the Minimum Data Set (MDS) for one of three residents reviewed. During the seven-day evaluation period, nursing progress notes indicated that the resident, who had moderate cognitive impairment and dementia following a stroke, refused multiple aspects of care daily, including medication, hygiene, and housekeeping, and exhibited yelling at staff. However, the MDS for the same period did not reflect any behaviors or refusals of care. The social worker confirmed that such behaviors should be documented in the MDS, and the facility was unable to provide a policy on MDS completion when requested.