Inaccurate MDS Vision Assessment for Legally Blind Resident
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident. Record review showed that this resident was admitted with diagnoses including blindness in one eye and acquired absence of the eye. Despite this, the resident’s Quarterly MDS, Section B (Hearing, Speech and Vision), dated 10/27/25, was coded as the resident having adequate vision. This coding conflicted with the resident’s documented medical history and diagnoses. Additional records reinforced that the resident had significant visual impairment. The care plan dated 10/15/25 identified the resident as being at risk for falls related to blindness in one eye and included interventions to arrange the environment to enhance vision, reposition items within the visual field, and monitor vision impairment as a factor in ADL decline. Physician orders dated 12/05/25 documented a referral to ophthalmology for loss of vision to the left eye and transfer to the emergency department for evaluation of blindness in that eye. During an interview, the MDS Coordinator acknowledged that the 10/27/25 MDS assessment was inaccurate and stated that the resident is legally blind and does not have adequate vision, and that it is her expectation that every MDS be completed with correct medical history and diagnoses.
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