Inaccurate MDS Assessments for Diagnoses and Oral Status
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two of nine residents reviewed. For one resident, documentation in the admission records, history and physical, and care plan all indicated diagnoses of chronic systolic and diastolic heart failure, as well as congestive heart failure. However, the resident's quarterly MDS assessment did not include any documentation of heart failure, despite confirmation from the DON and administrator that these diagnoses were present and should have been recorded in the MDS. For another resident, interviews and dental records confirmed the individual was edentulous, with no natural teeth, and this was also reflected in the care plan. Despite this, the annual MDS assessment did not document the absence of natural teeth or tooth fragments in Section L (Oral/Dental status). The administrator and Regional Nurse Consultant confirmed the resident's edentulous status and acknowledged the inaccuracy in the MDS documentation.