Inaccurate and Incomplete Resident Assessments Identified
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the status of two residents during significant change Minimum Data Set (MDS) assessments. For one resident, the Significant Change MDS assessment did not include the resident's preferences for customary routines and activities. The Activity Director did not complete Section F (Activity Preferences) of the MDS, and did not contact the resident's caregiver or staff to obtain this information, despite the resident being unable to communicate her preferences directly. The omission was acknowledged by the Activity Director, who stated she forgot to complete the staff assessment, and it was confirmed that the resident's activity preferences were not documented anywhere in the electronic medical record. For another resident, the Significant Change in Status MDS assessment inaccurately indicated that the resident did not have any unhealed pressure ulcers, despite medical records, wound care orders, and direct observation confirming the presence of a stage 3 pressure ulcer to the sacrum. The MDS was signed by a staff member who was not a current employee at the time of the assessment. The staff responsible for MDS oversight admitted that the coding was an error and that wound care documentation at the time of the assessment clearly indicated the presence of a pressure ulcer. Interviews with facility leadership, including the DON and Regional MDS Consultant, confirmed that all sections of the MDS are expected to be completed accurately by the appropriate staff, and that information should be gathered from all available sources, including caregivers and staff. The facility's policy requires that each portion of the MDS be completed and certified for accuracy by qualified staff, and that the information must reflect the resident's status during the observation period. In both cases, the assessments were incomplete or inaccurate, failing to capture essential information about the residents' conditions and preferences.