Inaccurate MDS Assessment of Resident's Hearing Ability
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for one resident when the resident's hearing ability was not properly coded. During observation and interviews, the resident was noted to be hard of hearing, did not have or use a hearing aid, and required questions to be repeated multiple times before responding. Both a CNA and an LVN confirmed the resident's hearing impairment. The resident's medical record documented a diagnosis of bilateral sensorineural hearing loss. However, the MDS assessment incorrectly coded the resident's hearing as adequate instead of highly impaired, as confirmed by the MDS Coordinator during a record review. This inaccuracy was contrary to the coding instructions in the CMS RAI Manual.