Inaccurate Resident Assessment for Hospice Services
Penalty
Summary
The facility failed to accurately complete a resident assessment for one of 35 residents reviewed. A review of the clinical record for this resident showed that the individual was assessed and evaluated by the hospice care team and subsequently admitted to hospice services with a diagnosis of cerebral atherosclerosis. Documentation included a physician order for hospice care services. However, the significant change Minimum Data Set (MDS) assessment completed for the resident did not indicate that hospice care was being provided, as Section O was marked 'no' for hospice care. This discrepancy was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the MDS was coded incorrectly for hospice care. The deficiency was identified through review of facility documentation, clinical records, and staff interviews, and it was determined that the facility did not ensure the resident's assessment accurately reflected the care and services being provided.