Inaccurate MDS Assessments and Discharge Documentation
Penalty
Summary
The facility failed to complete accurate and comprehensive Minimum Data Set (MDS) assessments for four residents. For three residents, the coding in Section B0700 indicated that the residents were at least sometimes understood by others, which should have prompted the completion of the Brief Interview for Mental Status (BIMS) in Sections C0200 through C0500. However, Section C0100 was incorrectly coded as 'No,' indicating the residents were rarely or never understood, and the BIMS interview was not completed as required. This discrepancy was confirmed by the Social Worker, who acknowledged the inaccurate coding on the MDS assessments for these residents. Additionally, for another resident, the discharge tracking MDS inaccurately recorded the discharge location. Nursing documentation showed that the resident was transferred to a local hospital for acute care, but the MDS indicated discharge to a nursing home. The Registered Nurse Assessment Coordinator confirmed that the wrong discharge location was entered on the MDS. These inaccuracies in the clinical records and MDS assessments were identified through review of the RAI User's Manual, clinical records, and staff interviews.