Incomplete MDS Cognitive Assessment
Penalty
Summary
Facility staff failed to provide a complete and accurate Minimum Data Set (MDS) assessment for one resident. The resident was admitted with multiple diagnoses, including metabolic encephalopathy, dysphagia, anemia, protein-calorie malnutrition, asthma, cognitive communication deficit, hypothyroidism, myocardial infarction, and hypertension. The MDS assessment dated [DATE] indicated that the section for cognitive patterns (Section C), which includes the Brief Interview for Mental Status (BIMS) and staff assessment of mental status, was not completed. All items in this section were marked as 'not assessed.' During an interview, the RN MDS coordinator confirmed that the cognitive section of the MDS had not been completed because the required assessment was not performed during the designated 7-day look-back period. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual specifies that the cognitive interview should be attempted with all residents during the look-back period, regardless of their ability to make themselves understood. This deficiency was confirmed through staff interview and clinical record review, with no additional information provided by facility leadership before the end of the survey.