Failure to Accurately Complete Comprehensive MDS Assessment
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were accurate and fully completed for one of eight residents. According to the facility's policy and the Resident Assessment Instrument (RAI) User's Manual, assessments such as the Brief Interview for Mental Status (BIMS) and the Resident Mood Interview should be conducted if the resident is at least sometimes understood. For the resident in question, clinical records indicated that the individual was not in a persistent vegetative state and was sometimes understood, both verbally and nonverbally. However, the MDS assessment marked the resident as rarely/never understood in the cognitive section, and as a result, the BIMS and Resident Mood Interview were not completed as required. Further review of the resident's MDS assessment showed inconsistencies, such as marking the resident as having a memory problem and being severely impaired in daily decision-making, but failing to complete the necessary cognitive and mood interviews. Instead, a staff assessment of mood was completed, which resulted in a severity score outside the expected range. During an interview, the Nursing Home Administrator confirmed that the facility did not ensure the accuracy and completeness of the MDS assessments for this resident.