Inaccurate and Incomplete MDS Assessments Identified
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were accurate and fully completed for several residents. Specific deficiencies included incorrect or incomplete coding in multiple MDS sections: cognitive patterns (Section C), mood (Section D), active diagnoses (Section I), swallowing/nutritional status (Section K), and special treatments, procedures, and programs (Section O). For example, residents who were sometimes or usually understood were incorrectly coded as rarely understood, resulting in the omission of required cognitive and mood interviews. Additionally, active diagnoses such as bipolar disorder, post-traumatic stress disorder, and dementia were not documented in the MDS for residents with those conditions, despite supporting clinical records and psychiatric evaluations. Further, the facility failed to accurately document special treatments and services, such as hospice care and continuous oxygen therapy, for residents who were actively receiving these interventions. In one case, a resident's weight used for the MDS assessment was outdated by more than 30 days, contrary to requirements. These findings were confirmed by interviews with the Registered Nurse Assessment Coordinator and the Nursing Home Administrator/Director of Nursing, who acknowledged the incomplete and inaccurate MDS assessments for multiple residents.