Inaccurate Resident Assessments in Dental, Respiratory, and Restraint Care
Penalty
Summary
The facility failed to ensure accurate assessments for several residents in key areas, including dental conditions, respiratory care, and the use of restraints. For two residents with dental issues, staff observations and interviews revealed missing, broken, and discolored teeth, yet the Minimum Data Set (MDS) assessments did not accurately reflect these conditions. In one case, a resident with quadriplegia and malnutrition had multiple missing and stained teeth, which were noted in progress notes and the initial nursing evaluation, but the MDS incorrectly indicated no dental issues. Another resident with broken and discolored teeth was also inaccurately assessed in the MDS, which failed to document their dental problems. A resident receiving oxygen therapy for chronic obstructive pulmonary disease (COPD) was not properly coded for oxygen use in the modified quarterly MDS, despite having a provider order and being observed on oxygen during multiple visits. Staff interviews confirmed that the resident was receiving oxygen therapy and that the MDS should have indicated this, but it was marked incorrectly. Additionally, a resident was incorrectly documented as using a partial trunk restraint in the quarterly MDS, although staff later confirmed this was an error and the resident did not use such restraints. These inaccuracies in resident assessments were confirmed through interviews with staff, including the MDS nurse and the Director of Nursing Services, who acknowledged the errors and stated that the MDS should have accurately reflected the residents' conditions. The failures in assessment were identified through a combination of record review, direct observation, and staff interviews, and were not known to some staff members responsible for coordinating care, such as the social worker.