Inaccurate and Incomplete MDS Assessments
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were accurate and fully completed for six out of fifteen residents. According to the Resident Assessment Instrument (RAI) User's Manual, specific sections of the MDS, such as Section C (Cognitive Patterns) and Section D (Mood), require completion of the Brief Interview for Mental Status (BIMS) and Resident Mood Interview if the resident is at least sometimes understood. However, for the identified residents, there were inconsistencies between their ability to be understood as documented in Section B (Hearing, Speech, and Vision) and the coding in Sections C and D, resulting in the required assessments not being completed. For example, several residents were documented as being 'usually' or 'sometimes' understood in Section B, but were coded as 'rarely understood' in Sections C and D, leading to the omission of the BIMS and Mood Interview assessments. This discrepancy was confirmed during an interview with the Director of Nursing, who acknowledged that the facility did not ensure the accuracy and completeness of the MDS assessments for these residents.