Failure to Accurately Document Tobacco Use on MDS Assessment
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the status of a resident with a history of chronic obstructive pulmonary disease (COPD) and daily tobacco use. Review of the resident's face sheet, care plan, and smoking safety screen confirmed that the resident smoked cigarettes daily, with staff storing and distributing smoking materials, lighting cigarettes, and supervising smoking breaks. Multiple interviews with the resident and staff, as well as direct observation, further confirmed the resident's ongoing tobacco use and the facility's supervision of her smoking activities. Despite this, the resident's admission Minimum Data Set (MDS) assessment did not indicate current tobacco use during the assessment period. The MDS nurse, responsible for completing all MDS assessments, acknowledged that the resident's tobacco use should have been marked but was overlooked. The Director of Nursing and Administrator also confirmed the oversight, stating that the MDS was not accurate in this instance. The facility's policy and the Resident Assessment Instrument (RAI) manual require accurate documentation of tobacco use, which was not followed in this case.