Inaccurate Resident Assessments Documented in MDS
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the health status and care needs of two residents. For one resident with a terminal diagnosis of severe COPD, respiratory failure, and hypoxia, hospice intake paperwork and ongoing hospice documentation confirmed a life expectancy of less than six months and continuous hospice services. However, multiple Quarterly Minimum Data Set (MDS) assessments did not indicate the resident's terminal prognosis, despite the resident remaining on hospice care throughout the period. The MDS Coordinator confirmed that these assessments were inaccurate and should have reflected the terminal prognosis. For another resident, the Quarterly MDS assessment documented that the resident rejected care on 1-3 days during the assessment period. However, a review of the Medication Administration Record and meal monitor showed that the resident refused medications and alternative meals on five of seven days during the same period. The MDS Coordinator acknowledged that the MDS was inaccurate and required modification to reflect the correct frequency of care rejection. These inaccuracies in resident assessments were identified through interviews and record reviews.