Incomplete MDS Cognitive Assessments for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and complete completion of the Minimum Data Set (MDS) cognitive assessment (Section C) for one resident. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus with diabetic autonomic neuropathy, a personal history of TIA and cerebral infarction without residual deficits, a cognitive communication deficit, and depression. These conditions were documented on the resident’s face sheet and establish that the resident had relevant cognitive and neurological history at the time the MDS assessments were due. Multiple MDS assessments for this resident, each with different assessment dates, showed repeated omissions and unanswered items in Section C (Cognitive Patterns). On one MDS, the item asking whether the Brief Interview for Mental Status (BIMS) should be conducted (C0100) was left unanswered, and all BIMS items (C0200–C0500) were unanswered, resulting in no BIMS score, while the staff assessment for mental status (C0600) was also dashed. Despite these omissions, short-term memory (C0700) and cognitive skills for daily decision making (C1000) were coded as “memory ok” and “modified independence.” On subsequent MDS assessments, C0100 was sometimes coded “yes,” but the BIMS items (C0200–C0500) were dashed, C0600 remained dashed, and short-term and long-term memory items (C0700, C0800) were also dashed, again resulting in the absence of a BIMS score. Across several MDS assessments, this pattern of incomplete coding persisted: key cognitive assessment items were either left unanswered or dashed, including the decision to conduct BIMS, the BIMS questions themselves, the staff assessment for mental status, and memory items. During an interview, the MDS Coordinator stated she was responsible for completing these MDS assessments for the resident and acknowledged that it was her expectation that the assessments, including Section C, be fully completed and not dashed or left unanswered. The documented record review and the MDS Coordinator’s statements together show that the facility did not ensure an accurate and fully completed MDS cognitive assessment for this resident.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.