Inaccurate MDS Assessment of Resident's Vision Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's vision status. Multiple staff members, including the Director of Nursing, an LPN, and the MDS Coordinator, confirmed that the resident was blind. Observations showed the resident required assistance to exit the room, bumped into walls, and relied on verbal directions from a roommate. Despite these clear indications of visual impairment, the most recent MDS assessment documented the resident's vision as adequate. A review of the resident's records revealed a history of Parkinson's Disease and Schizophrenia, and a fall assessment from earlier in the year indicated an inadequate vision pattern. The resident was cognitively intact, as evidenced by a BIMS score of 15. Staff interviews and documentation confirmed awareness of the resident's blindness, yet this was not accurately reflected in the MDS or care plan as required by facility policy and CMS protocol.