Inaccurate MDS Assessment and Omission of Diagnoses
Penalty
Summary
The facility failed to ensure that a resident's Significant Change Minimum Data Set (MDS) assessment accurately reflected the resident's current status. Specifically, the assessment did not document that the resident required total assistance of two persons for bed mobility, nor did it include both of the resident's active autoimmune skin disease diagnoses. The resident's medical record indicated a history of diabetes mellitus, osteoarthritis, rheumatoid arthritis, pemphigus vulgaris, and Stevens-Johnson Syndrome, with multiple skin lesions and impaired activities of daily living. However, the MDS only listed Stevens-Johnson Syndrome and reduced mobility, omitting pemphigus vulgaris. Interviews and record reviews revealed that staff were not consistently informed about the resident's care needs, and direct care staff did not always have access to information regarding the level of assistance required for activities of daily living. For example, a CNA reported not receiving a report at the start of the shift and lacking access to the electronic system to verify care requirements. The facility's policy required comprehensive review and validation of resident status during the MDS assessment process, but this was not followed, resulting in an inaccurate assessment.