Inaccurate MDS Assessments for Tobacco Use, Nutrition, and PASRR Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the current status of five residents. For several residents who used tobacco products, including cigarettes and smokeless tobacco, the MDS assessments did not indicate current tobacco use, despite documentation in care plans, smoking safety screens, and direct observations of tobacco use during the assessment periods. Interviews with the residents confirmed their ongoing tobacco use, and staff, including the RN and MDS nurse, acknowledged that these residents used tobacco daily. However, the MDS assessments for these residents were not coded to reflect this, resulting in inaccurate documentation. In another instance, a resident was incorrectly coded on the MDS as receiving a feeding tube for nutritional support, despite physician orders, care plans, and direct observation confirming that the resident was on a mechanical soft diet and had never had a feeding tube. The MDS nurse admitted to coding this incorrectly, attributing the error to a busy admission day. The DON also acknowledged the error and recognized that it could impact the resident's care. Additionally, a resident with a diagnosis of cerebral palsy and a positive PASRR for intellectual and developmental disabilities (ID/DD) was not coded appropriately on the MDS. The care plan and physician documentation indicated the presence of ID/DD, but the MDS assessment did not reflect this. The MDS nurse admitted to coding the PASRR status incorrectly. Throughout these cases, the facility's policy required accurate and timely completion of the MDS based on direct observation, interviews, and record review, but these requirements were not met for the residents involved.