Inaccurate MDS Assessment of Dental Status
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments were completed for a resident with a history of stroke who was admitted in April 2020. Observations on two separate occasions revealed the resident had no upper teeth, missing lower molars, and experienced difficulty chewing certain food textures such as cucumbers and large pieces of lettuce. The resident reported missing upper teeth with three broken tooth fragments and missing teeth on both sides of the lower mouth, as well as difficulty chewing hard food items. However, the resident's quarterly and annual MDS assessments indicated no cognitive impairment, no difficulty chewing food, and no natural teeth or tooth fragments, with no obvious or likely broken natural teeth. The Director of Nursing Services confirmed that the MDS assessments were inaccurate and did not reflect the resident's actual dental status.