Inaccurate MDS Assessments for Weight Loss and Dialysis
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the clinical status of two residents. For one resident, the MDS assessment did not document a significant weight loss, despite clinical records showing a decrease from 123 pounds to 107 pounds within a month, which constitutes a 13% weight loss. The Registered Dietitian confirmed that this weight loss was not accurately recorded in Section K0300 of the MDS, resulting in an inaccurate assessment of the resident's nutritional status. For another resident with end-stage renal disease receiving maintenance hemodialysis, the MDS assessment failed to indicate that the resident was receiving dialysis treatments, even though clinical records showed dialysis was administered on multiple occasions. The Registered Nurse Assessment Coordinator confirmed that the omission in Section O0110 of the MDS was an error. These inaccuracies were identified through clinical record reviews and staff interviews, and they represent a failure to ensure that assessments accurately reflected the residents' conditions as required by regulatory standards.