Inaccurate MDS Assessments and Incomplete Functional Status Documentation
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents. For one resident with a documented history of bipolar disorder, generalized anxiety disorder, post-traumatic stress disorder, and sleep terror, the MDS assessment incorrectly indicated that the resident was not considered by the state PASRR Level II process to have a serious mental illness, despite documentation to the contrary. This inaccuracy was confirmed by the MDS coordinator during an interview. Another resident's annual MDS assessment had section GG, which evaluates functional abilities and goals, marked as not assessed. The MDS coordinator stated that this section was dashed out because staff were not available at the time to perform the assessment. The RAI manual specifies that section GG is intended to capture important information about a resident's functional status, including self-care and mobility activities. These findings were based on medical record review, staff interviews, and reference to the MDS RAI manual.