Inaccurate MDS Assessments of Oral Health Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the oral health status of two residents. For one resident with severe cognitive impairment and a history of dementia, depression, and anxiety, the significant change MDS assessment incorrectly indicated that she had all her natural teeth without problems, despite observations and interviews confirming she had no teeth and was missing her dentures. This resident expressed difficulty eating her provided diet and reported that her dentures had been lost at the facility. Her care plan documented dental problems related to missing dentures, but this was not reflected in the MDS assessment. Another resident, also with severe cognitive impairment and multiple medical diagnoses including vascular dementia and multiple sclerosis, had a comprehensive MDS assessment that failed to note her decaying and missing teeth. Dental records indicated several decayed teeth and a missing crown, and the resident reported pain and a desire to see a dentist. During interviews, both the MDS coordinator and the corporate MDS nurse acknowledged that the assessments were coded incorrectly and did not accurately represent the residents' oral health status.