Failure to Accurately Complete Resident Assessments and MDS Documentation
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status for four out of 29 residents reviewed. Specifically, for two residents, the Brief Interview for Mental Status (BIMS) was not conducted as required, and Section C of the Minimum Data Set (MDS) was left incomplete. The Registered Nurse Assessment Coordinator confirmed that the BIMS assessments should have been completed but were not done in time for the MDS submission, resulting in missing information. Additionally, for another resident with a tracheostomy and a diagnosis of respiratory failure, the comprehensive MDS did not indicate that the resident received suctioning and tracheostomy care, despite these interventions being documented in the care plan. In a separate case, a resident's discharge status was incorrectly coded on the MDS as a discharge to a short-term hospital, when the clinical record showed the resident was discharged home with prescriptions and instructions. These findings were based on clinical record reviews and staff interviews.