Inaccurate MDS Assessment and Failure to Update Care Plan for Resident with Hearing Loss
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected the resident's cognitive status and use of hearing aids. The resident, who had diagnoses including unspecified dementia, Alzheimer's disease, depression, and muscle weakness, experienced a significant change in cognitive status as recorded in the MDS assessment. However, the assessment inaccurately indicated that the resident was using hearing aids, despite documentation that the hearing aids had been lost prior to the assessment period. The MDS also did not accurately reflect the resident's true cognitive abilities, as the Brief Interview for Mental Status (BIMS) was conducted while the resident was missing one or both hearing aids, impacting her ability to respond to questions. Review of the resident's care plan and electronic medical record revealed that interventions for communication strategies were not updated after the loss of the hearing aids. The care plan continued to reference the use of hearing aids and did not include alternative communication methods, such as the use of a whiteboard, which staff later reported as effective. Progress notes and interviews with staff confirmed that the resident had a history of losing hearing aids and that the family was no longer able to replace them. Despite this, there was no documentation of care plan revisions or updated interventions to address the resident's hearing loss and communication needs after the hearing aids were lost. Interviews with facility staff, including the social worker, MDS nurse, and DON, revealed a lack of awareness and communication regarding the use of alternative communication methods and the need to update care plans and assessments accordingly. Staff acknowledged that the resident's low BIMS scores were likely influenced by her inability to hear the questions, and that the care plan should have been revised to reflect her current status and needs. The facility's policies require that assessments and care plans be accurate, comprehensive, and updated in response to significant changes in a resident's condition, but these requirements were not met in this case.