Failure to Accurately Complete MDS for Resident with Significant Weight Loss
Penalty
Summary
The facility failed to accurately complete Section K of the Minimum Data Set (MDS) for a resident who experienced significant weight loss. Specifically, the resident's weight dropped from 230.3 pounds to 206.6 pounds between two documented dates, representing a 10.29% loss. However, the 5-day MDS assessment did not indicate a weight loss of 5% or more in the last month as required. This omission was confirmed by the MDS Nurse, who acknowledged that the weight loss should have been captured but was missed. The resident involved had a history of chronic kidney disease stage 3 and chronic systolic congestive heart failure and was severely cognitively impaired, as indicated by a Brief Interview for Mental Status (BIMS) score of 3. The DON stated that her expectation was for MDS staff to accurately reflect the resident's status at the time of assessment. The facility's policy requires that the Resident Assessment Instrument (RAI) be completed according to CMS guidelines, but this was not followed in this instance.