Inaccurate MDS Assessment of Tobacco Use
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the status of a resident with chronic obstructive pulmonary disease. The resident's face sheet and care plan indicated that he was a smoker, and a progress note also documented current tobacco use. However, the Comprehensive MDS assessment did not indicate tobacco use for this resident. The MDS Coordinator responsible for completing the assessment acknowledged that the resident should have been coded for tobacco use and admitted to overlooking this information during the assessment process. The facility's policy requires the use of the most up-to-date Resident Assessment Instrument (RAI) manual to ensure accurate and timely coding of each section of the Resident Assessment. The Administrator confirmed that MDS Coordinators are responsible for accurate coding and stated that if the MDS is not coded according to the resident's plan, the interventions in place would not be beneficial to the patient. The deficiency was identified through interview and record review, which revealed the inconsistency between the resident's documented tobacco use and the information recorded in the MDS assessment.