Failure to Accurately Complete MDS Assessments and Cognitive Status Interviews
Penalty
Summary
The facility failed to ensure accurate and complete Minimum Data Set (MDS) assessments for five residents, resulting in deficiencies related to cognitive status, diagnoses, and communication abilities. For several residents, the Brief Interview for Mental Status (BIMS) was not conducted as required, despite documentation and staff interviews indicating that the residents were able to understand, be understood, and participate in interviews. Instead, staff completed the Staff Assessment for Mental Status (SAMS) or incorrectly coded the MDS, bypassing the resident interview process without appropriate justification. In one case, a resident who was non-verbal but able to communicate via written means or technology was not given a written BIMS assessment, contrary to protocol. Additionally, there were discrepancies in the documentation of diagnoses. For one resident, the MDS did not reflect a diagnosis of dementia or Alzheimer's disease, despite multiple physician notes in the medical record indicating a diagnosis of dementia. Staff interviews confirmed that the provider's documentation should have been recognized and incorporated into the MDS, but this was not done, resulting in an inaccurate assessment. Another resident's MDS was not assessed for BIMS despite the resident being present and able to participate, as confirmed by staff. The Resident Assessment Instrument (RAI) Manual requires that staff attempt a BIMS on all residents unless specific criteria are met, such as the resident being rarely or never understood or unable to respond by any method. The facility's failure to follow these guidelines led to incomplete and inaccurate assessments regarding residents' cognitive status, communication, and diagnoses, as evidenced by the review of records and staff interviews.