Inaccurate Resident Assessment Documentation
Penalty
Summary
The facility failed to ensure that assessments accurately reflected a resident's status for one out of three residents reviewed. Specifically, a resident admitted with diagnoses including dementia, an intracapsular fracture of the right femur, and type 2 diabetes mellitus was evaluated by Physical Therapy and found to require maximum assistance for bed mobility. However, the admission Minimum Data Set (MDS) documented the resident as dependent for bed mobility, which did not align with the Physical Therapy evaluation. The facility also lacked a policy related to the MDS assessment process. Further review of the resident's care plan indicated a self-care performance deficit due to activity intolerance, confusion, and disease processes, with interventions focused on encouraging participation in self-care. Interviews with nursing staff revealed that the rehabilitation department completed the functional assessment section of the MDS, which was then signed off by nursing. Staff noted that the resident was coded as dependent for bed mobility and questioned the absence of turning and positioning orders or heel elevation. Attempts to interview the Physical Therapist involved were unsuccessful.