Failure to Accurately Document Resident Assessments
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current status of two residents. For one resident with a history of stroke, diabetes, depression, and mild cognitive impairment, the quarterly Minimum Data Set (MDS) assessment did not document left-sided hemiplegia and hemiparesis as a functional limitation in range of motion or as a diagnosis, despite multiple records and staff interviews confirming total dependence for activities of daily living (ADLs), use of a mechanical lift, and paralysis on the left side. The care plan, transfer records, and staff interviews consistently described the resident as bed- or wheelchair-bound, requiring maximal assistance, yet the MDS failed to capture these significant limitations. For another resident with severe cognitive impairment and a diagnosis of unspecified dementia, the quarterly MDS assessment did not initially document wandering behavior in Section E, even though the resident was observed walking throughout multiple hallways and had a documented history of wandering. The resident was care planned for use of a wander guard bracelet, had a daily order for a wander device alarm, and was visually checked for the device every shift. Staff interviews and observations confirmed frequent wandering behavior, but the MDS did not reflect this until it was later modified. The deficiencies were identified through interviews, observations, and record reviews, which revealed inconsistencies between the residents' actual conditions and the information documented in their MDS assessments. Staff responsible for completing the MDS acknowledged the errors and attributed them to oversight, resulting in assessments that did not accurately represent the residents' functional limitations or behaviors as required by federal regulations.