Inaccurate MDS Assessment Following Resident's Decline
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment for a resident was completed accurately, resulting in the omission of significant changes in the resident's condition. The resident, who had a history of diabetes, hypertension, chronic kidney disease, and a right tibial fracture, was observed to have new functional limitations in the right upper extremity and speech impairments. Despite these changes, the MDS quarterly assessment did not reflect the resident's inability to lift her right arm, her speech difficulties, or the presence of neurological issues such as aphasia. Multiple records, including progress notes, a speech language pathologist evaluation, and an interdisciplinary care conference, documented the resident's decline, but these were not incorporated into the MDS assessment. Interviews with facility staff, including the LVN/Director of Staff Development and the Chief Nursing Officer, confirmed that the MDS assessment was inaccurate and that no change of condition assessment had been initiated, even though the resident's decline had persisted for over 14 days. The facility's policy required a significant change in status assessment MDS to be generated within 14 days of a change in condition, but this was not done. As a result, the resident's assessment did not accurately represent her current status, as verified by staff and documentation.