Failure to Accurately Complete MDS Assessment for Resident with Multiple Diagnoses
Penalty
Summary
The facility failed to ensure that a resident received an accurate assessment reflective of their current status, specifically regarding the completion of the Minimum Data Set (MDS) assessment. Record review showed that the resident, a male with multiple complex diagnoses including quadriplegia, diabetes, chronic kidney disease, neurogenic bladder, and major depressive disorder, had an MDS assessment that did not include several of his active diagnoses such as coronary artery disease, neurogenic bladder, quadriplegia, or depression. The resident was cognitively intact, used a wheelchair, and was dependent for most activities of daily living (ADLs). Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for the accuracy and completion of the MDS. The DON stated that although her signature appeared on the MDS, she could not verify it and was not informed she should review the MDS for accuracy. The Administrator and VPO both indicated that the facility did not have a current MDS Coordinator at the time, and that oversight was expected from either the DON or a Regional MDS Coordinator, who had also recently been terminated. The facility did not have a specific MDS policy and relied on the RAI manual. This lack of accurate assessment and clear responsibility could result in residents not receiving appropriate care and services.