Inaccurate MDS Assessment of Resident Behaviors
Penalty
Summary
The facility failed to ensure that assessments accurately reflected a resident's behavioral status, as evidenced by discrepancies between the resident's care plan, staff interviews, and the Minimum Data Set (MDS) documentation. The resident in question had a history of severe cognitive impairment, fluctuating behaviors, and multiple diagnoses including COPD, muscle weakness, depression, and a history of elopement and resistance to care. Despite these documented behaviors and staff observations of combative and resistant actions, the resident's Quarterly and Discharge MDS assessments indicated that no behavioral symptoms, rejection of care, or wandering were exhibited. Record reviews showed that the resident's care plan included specific notes about wandering, elopement risk, disorientation, frequent refusal of ADL care, yelling at other residents, and removing medical devices. Multiple staff interviews corroborated that the resident was confused, attempted to elope, was resistant to care, and displayed both physical and verbal behavioral symptoms. Staff described the resident as combative, not friendly, and prone to rejecting care several times a week. However, these behaviors were not reflected in the MDS assessments, which were marked as not exhibited for all behavioral symptoms. The MDS nurse, who was new and did not complete the resident's assessments, stated that the MDS is compiled using information from the interdisciplinary team, interviews, and observations. The DON confirmed that the MDS assessments for the resident were inaccurate and did not acknowledge the resident's physical, verbal, and other behavioral symptoms. Facility policy requires comprehensive and accurate assessments to inform care planning, but this was not followed in the resident's case, resulting in inaccurate documentation of the resident's needs and behaviors.