Inaccurate MDS Assessment of Care Refusals
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident. Specifically, the MDS assessment for this resident did not accurately reflect multiple documented instances of care and evaluation refusal during the seven-day look-back period. Progress notes in the electronic medical record showed that the resident repeatedly refused blood pressure monitoring and therapy screening, and these refusals were confirmed by both nursing and therapy staff. However, the quarterly MDS assessment indicated that the resident did not reject care or evaluation, which was inconsistent with the documented evidence in the resident's records. Interviews with facility staff, including a Licensed Practical Nurse and the Social Worker responsible for completing the MDS, confirmed that the resident had refused care on several occasions. The Social Worker acknowledged that the MDS was inaccurate after reviewing the progress notes and the assessment. The facility's policy requires staff to attest to the accuracy of the sections they complete in the MDS, but this process was not followed in this instance, resulting in an inaccurate assessment.