Inaccurate MDS Weight Documentation on Admission
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's weight status at admission. Specifically, the admission MDS for a male resident with multiple complex diagnoses, including traumatic brain injury, malnutrition, and dysphagia, documented his weight as 154 pounds, which was taken from hospital records rather than an actual weight measurement at the facility. The resident's weight was not obtained upon admission due to his agitation, and the admitting nurse deferred the task to another staff member, who did not complete it. As a result, the MDS Coordinator used the hospital discharge weight to complete the assessment for billing purposes, without verifying the resident's current weight at the facility. Record reviews showed that the resident's actual weight was not documented until several days after admission, at which point it was recorded as 138 pounds. The nurse's notes at admission indicated that no weight was documented, and the MDS Coordinator later acknowledged that she should have ensured the resident was weighed at the facility before completing the MDS. The facility's policy requires comprehensive and accurate assessments using the RAI process, with all disciplines following the guidelines for coding each assessment, but this protocol was not followed in this instance. Interviews with staff revealed a lack of communication and follow-through regarding the resident's weight assessment. The admitting nurse was unaware that the weight had not been obtained, and the MDS Coordinator admitted to relying on hospital records instead of current facility data. The Director of Nursing stated that nurses are expected to conduct proper assessments, including reviewing CNA documentation and nurse progress notes, but this was not done for this resident's admission weight.