Inaccurate Resident Assessments Documented in MDS
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current status of four residents, as required by policy and regulatory guidelines. For one resident with hemiplegia and moderate protein-calorie malnutrition, the Minimum Data Set (MDS) assessment contained conflicting information regarding the presence of a pressure ulcer. Specifically, the assessment indicated both the absence and presence of a pressure ulcer, with further details showing a Stage 3 pressure ulcer documented. The Director of Nursing (DON) confirmed the inaccuracy in the MDS coding for this resident. Another resident with nicotine dependence and hypertension was care planned for regular evaluation of safe smoking practices. However, the annual MDS assessment incorrectly indicated that the resident was not a current tobacco user, despite the resident's own statement and care plan documentation confirming daily supervised smoking. Similarly, a different resident with nicotine dependence and diabetes mellitus was also care planned for safe smoking but had their MDS assessment marked as not using tobacco and did not have nicotine dependence listed in the active diagnoses section, contrary to the clinical record and care plan. A further deficiency was identified for a resident with expressive aphasia and a history of stroke. The quarterly MDS assessment coded the resident's speech as clear, while observations, care plan documentation, and staff interviews indicated that the resident's speech was slurred and communication was primarily conducted through writing on a whiteboard. The DON acknowledged that the MDS should have reflected unclear speech based on the resident's documented status and care plan notes.