Inaccurate Resident Assessment Documentation
Penalty
Summary
The facility failed to ensure that the resident assessment accurately reflected the status of one resident. Specifically, the Minimum Data Set (MDS) for this resident indicated that the resident had adequate hearing and no deep tissue injuries, despite multiple sources documenting otherwise. The resident's admission records and weekly wound assessment showed the presence of a deep tissue injury (DTI) on the right heel, and interviews with staff and the resident confirmed significant hearing impairment and the use of hearing aids, which were currently missing. The MDS, however, did not reflect these conditions, listing the resident as having adequate hearing and no DTI. Interviews with facility staff, including the Assistant Administrator, Licensed Vocational Nurse, and Director of Nursing, confirmed the discrepancies between the resident's actual condition and what was documented in the MDS. The Director of Nursing acknowledged that the MDS was inaccurate in the sections related to hearing and skin conditions. The facility's policy requires that assessments be accurate and reflective of the resident's status at the time of assessment, but this was not followed in this case.