Failure to Accurately Reflect Resident Diagnoses in MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected all current medical diagnoses. Specifically, the MDS did not include a diagnosis of dementia, despite this being documented in the resident's History and Physical (H&P) by the primary physician. The MDS Coordinator acknowledged that during the assessment process, staff relied on the existing admission record rather than reviewing the most recent H&P for new or updated diagnoses. This omission was identified during a review of the resident's records and confirmed in interviews with both the MDS Coordinator and the Director of Nursing (DON). The DON stated that it is the responsibility of the MDS Coordinator to ensure that all diagnoses from the primary physician's notes are accurately reflected in the MDS and the resident's care plan. The facility's policy requires that the Resident Assessment Instrument (RAI) process includes comprehensive and up-to-date information about the resident's health status at the time of assessment. The failure to update the MDS with the dementia diagnosis resulted in an inaccurate assessment for the resident.