Inaccurate MDS Assessment of Transfer Needs
Penalty
Summary
The facility failed to ensure that assessments accurately reflected a resident's status, specifically for one resident who was reviewed for assessment accuracy. The quarterly Minimum Data Set (MDS) submitted on 1/22/2025 did not indicate that the resident required a mechanical lift for transfers, despite documentation and staff interviews confirming that the resident had required the use of a mechanical lift since admission. The resident's care plan included fall prevention measures involving the use of a Hoyer lift, and the Certified Occupational Therapy Assistant (COTA) confirmed the resident was unable to stand or bear weight at all. The Assistant Director of Nursing (ADON), who was serving as the MDS nurse, stated she was still in training and had not completed the prior two MDS submissions for this resident. She was unable to explain why the earlier assessment failed to document the need for a mechanical lift, even though she recalled the resident had always required it. The resident was noted to have severely impaired cognition and was unable to be interviewed during the survey. The inaccurate assessment could result in the resident not receiving the required care.