Incomplete MDS and CAA Documentation for Pressure Ulcers and Nutrition
Penalty
Summary
The facility failed to complete required Minimum Data Set (MDS) assessments and Care Area Assessment (CAA) worksheets for two residents. For one resident with no cognitive impairment, the MDS documented two unstageable pressure ulcers that developed during the stay. The CAA worksheet for pressure ulcers was incomplete, as it did not describe the impact, rationale for care planning, risk factors, or need for referral to other health professionals. Staff interviews confirmed that the resident had not developed new pressure ulcers since admission, and the MDS Coordinator responsible for completing the assessments worked offsite. For another resident with severe cognitive impairment and diagnoses including Parkinson's, dehydration, and depression, the CAA worksheet for nutrition was also incomplete. The resident experienced significant weight loss and was on hospice care, but the worksheet lacked documentation of the impact, rationale, risk factors, and referral needs. A weight/skin summary note indicated a meeting with the ADON and dietician regarding the weight loss, but the required CAA documentation was not completed. Attempts to contact the MDS Coordinator were unsuccessful.