Inaccurate MDS Assessments for Hospice Services and Tobacco Use
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments, specifically regarding the documentation of hospice services and tobacco use. Medical record reviews for six residents who were receiving hospice care showed that their Minimum Data Set (MDS) assessments did not indicate the provision of hospice services, despite clear documentation in their medical records that hospice care had been initiated. This was confirmed in an interview with the MDS nurse, who acknowledged that the MDS assessments for these residents did not reflect their hospice status. Additionally, a review of another resident's records revealed a discrepancy regarding tobacco use. The resident's medical record and smoking assessment indicated a long history of smoking and current use requiring supervision, but the admission MDS assessment incorrectly documented that the resident did not use tobacco. The MDS nurse confirmed she was unaware of the resident's smoking status at the time of completing the assessment and verified the error in the MDS documentation.