Inaccurate MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to ensure an accurate assessment for one resident who was receiving hospice care. The Minimum Data Set (MDS) assessment, specifically Section O which documents special treatments and programs, was completed by the MDS Director but did not indicate that the resident was under hospice care, despite documentation in the clinical census and physician's orders confirming hospice services. During interviews and record reviews, the MDS Director acknowledged responsibility for completing Section O and confirmed that the resident should have been coded as receiving hospice care, but was not. Further review of facility policy revealed that assessments are to be completed by qualified staff and must accurately reflect the resident's status, with all contributors attesting to the accuracy of the information. The Director of Nursing confirmed that the assessment was inaccurate and that facility policy was not followed in this instance. The resident involved had diagnoses including COPD and cirrhosis of the liver and was admitted to hospice care, but this was not reflected in the MDS assessment.