Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two of three sampled residents. For one resident with multiple diagnoses including heart disease, dementia, and chronic obstructive pulmonary disease, the MDS assessment inaccurately documented the resident as a non-smoker. However, record reviews and staff interviews confirmed that the resident was identified as a smoker upon admission, had a smoking assessment completed, and had a care plan in place addressing smoking safety, with cigarettes and lighter kept at the nurse's station. Both the administrator and assistant directors of nursing confirmed the omission on the MDS assessment. For another resident with diagnoses including Parkinson's disease and chronic obstructive pulmonary disease, the MDS assessment inaccurately indicated the absence of an ostomy and dependence with toileting hygiene. In contrast, the resident's care plan documented a colostomy and included interventions for colostomy care and monitoring for skin breakdown. The director of nursing confirmed that the MDS assessment was inaccurate regarding the resident's colostomy status.