Inaccurate Resident Assessments Completed During Hospitalization
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status for four residents reviewed. Specifically, BIMS (Brief Interview for Mental Status) and PHQ (Patient Health Questionnaire) assessments were completed for these residents while they were hospitalized and not present in the facility, resulting in the resident interviews not being conducted. The assessments were documented as completed during the residents' hospital stays, as confirmed by census data and assessment dates. The residents involved had complex medical histories, including conditions such as anemia, atrial fibrillation, dementia, schizoaffective disorder, osteomyelitis, cerebral infarction, and other chronic illnesses. Interviews with facility staff revealed that the social worker completed the assessments during the residents' hospitalizations because the MDS Nurse indicated they were due, and the social worker was unsure how to complete discharge assessments when the resident was not available for interview. The administrator stated that assessments should be coded as not assessed if the resident is in the hospital, but believed the error was due to inaccurate data entry. The facility did not have a specific policy for resident assessments.