Failure to Complete and Accurately Reflect Resident Status in MDS Assessments
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments accurately reflected the healthcare status and needs of two residents. For one resident, the admission MDS assessment was not completed, despite the resident having multiple diagnoses including encephalopathy, congestive heart failure, hypothyroidism, and muscle weakness. Documentation showed that the resident had a care plan addressing wound care and infection risk, and physician orders for wound treatment were present, but the required MDS assessment was missing. For the second resident, only Section F (Preferences for Customary Routine and Activities) of the comprehensive MDS assessment was completed and signed, with the remainder of the assessment left incomplete. Interviews with staff revealed that the process for completing MDS assessments involved both onsite and remote staff. The LVN responsible for entering assessment data stated that most assessments were conducted by facility staff and then compiled by remote workers, but he was not responsible for ensuring timely completion. The VPR, who was responsible for submitting MDS assessments, acknowledged delays due to an unfilled MDS position and confirmed that incomplete or late assessments could result in not identifying residents' care needs. The facility's policy required all MDS assessments to be completed and transmitted in accordance with OBRA regulations, but this was not followed for the two residents in question.