Inaccurate MDS Assessment Due to Incorrect Primary Language Documentation
Penalty
Summary
Facility staff failed to complete an accurate Minimum Data Set (MDS) assessment for a resident with multiple diagnoses, including chronic respiratory failure with hypoxia, COPD, Parkinson's disease, and paroxysmal atrial fibrillation. The resident's face sheet indicated an admission date and listed these diagnoses. Multiple MDS assessments documented the resident's primary language as English. However, interviews with nursing staff, a CNA, and the Social Services Assistant revealed that the resident primarily spoke Navajo and understood Navajo better than English. Staff reported that they often needed to find a Navajo-speaking staff member to translate for the resident. Further, the Social Services Assistant, who spoke Navajo fluently, completed the resident's Brief Interview of Mental Status (BIMS) in English on one occasion, resulting in a score indicating moderate cognitive impairment. When the BIMS was later conducted in Navajo, the resident scored higher, suggesting better cognitive function when assessed in their primary language. The Social Services Director acknowledged that the discrepancy in BIMS scores was likely due to the language used during the assessment and confirmed that the MDS should have reflected Navajo as the resident's primary language.