Inaccurate MDS Assessment of Oral/Dental Status
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected her oral and dental status. Specifically, the MDS assessment indicated that the resident had no dental issues, as the box for 'None of the above were present' was checked in Section L - Oral/Dental Status. However, record review and interviews revealed that the resident had broken natural teeth, which was documented in a psychosocial note and observed during an interview. The resident herself acknowledged having broken teeth, though she stated they did not cause her pain and she did not wish to have them fixed. Further review showed that the resident's care plan noted her refusal of dental care, and staff interviews confirmed that oral care was being provided and any changes were reported to nursing staff. The Director of Nursing acknowledged that the MDS should be coded as accurately as possible and that inaccuracies could affect the overall assessment and care provided. The facility's policy requires resident information to be as accurate and truthful as possible, but this was not followed in the case of the resident's dental status.