Failure to Accurately Reflect Resident Behaviors in MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) quarterly assessment accurately reflected the resident's behavioral status. Specifically, the MDS assessment for a male resident with dementia, personality change, and hypertension did not indicate the presence of physical or verbal behaviors, despite documentation in the clinical record showing that the resident had exhibited inappropriate remarks and behaviors toward staff during the assessment's look-back period. Behavior notes from nursing staff documented incidents of inappropriate remarks to a female medication aide and inappropriate behavior toward a nurse, with interventions such as redirecting the resident to his room. The MDS Coordinator confirmed that the facility follows the RAI manual for assessments and acknowledged that inaccurate MDS completion could result in care needs not being properly addressed in the care plan. The Assistant Director of Nursing (ADON) stated that the Director of Nursing (DON) is responsible for ensuring MDS accuracy, and the Clinical Services Director emphasized that behavioral symptoms should be captured in the MDS to ensure appropriate care planning. The RAI manual specifies that behavioral symptoms present in the last seven days should be coded accordingly, but this was not done for the resident in question.