Inaccurate Resident Assessment on MDS
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' current status for two of six residents reviewed. Specifically, for one resident, the quarterly Minimum Data Set (MDS) assessment incorrectly indicated that the resident was in a comatose or persistent vegetative state. This error caused several key assessment sections, including cognitive patterns, mood, and behavior, to be skipped. Direct observation showed the resident was conscious, able to converse, and followed staff instructions. The resident also confirmed in an interview that he had not been in a comatose state during his stay at the facility. The MDS Coordinator acknowledged being unaware of the error and stated it was a typographical mistake, confirming that the resident had never been comatose while at the facility. The Director of Nursing (DON) reported that she conducts random reviews of MDS assessments but was not aware of this specific error. The DON also clarified that the MDS Coordinator is responsible for completing MDS assessments for each resident. These actions and inactions led to the inaccurate documentation of the resident's condition.