Inaccurate Resident Assessments Documented
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the status of two residents. For one resident with diagnoses including palliative care, Parkinson's disease, and dysphagia, the Minimum Data Set (MDS) did not indicate the presence of a PASRR level II, despite documentation in the medical record and confirmation by staff that the resident had a PASRR level II related to serious mental illness, post-traumatic stress disorder, and major depressive disorder. For another resident with diagnoses including dementia, pacemaker, post-traumatic stress disorder, and chronic kidney disease, the discharge MDS incorrectly coded the resident as being discharged to a short-term general hospital, while progress notes and staff interviews confirmed the resident was actually discharged home on hospice. These inaccuracies were identified through interviews with facility staff and review of medical records, demonstrating that the assessments did not accurately reflect the residents' actual conditions or discharge locations.