F0641

D

Inaccurate MDS Assessments for Diet and Respiratory Treatments After Change in Condition

Dallas, Texas Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

Surveyors identified a failure to ensure that a resident’s Minimum Data Set (MDS) assessments accurately reflected the resident’s current clinical status, specifically related to diet and respiratory treatments. Record review showed that the resident, an older male with diagnoses including metabolic encephalopathy, diabetes mellitus with hyperosmolality, hypernatremia, and acute and chronic respiratory failure with hypoxia, had an MDS dated 09/09/2025 with an undocumented assessment type and an empty BIMS summary score field. This MDS documented shortness of breath with exertion, at rest, and when lying flat, and noted parenteral/IV feeding while not a resident, but did not clearly capture subsequent clinical changes. The resident was hospitalized multiple times and returned with changes in diet approaches, including thickened liquids, and with respiratory treatments and IV for enteral feeding.

The quarterly MDS completed later by an LVN/MDS nurse documented a BIMS score of 07, indicating severe cognitive impairment, and again noted shortness of breath with exertion, at rest, and when lying flat. In Section K, the quarterly MDS continued to list parenteral/IV feeding as a nutritional approach but did not address the resident’s need for thickened liquids. In Section O, the assessment indicated that the resident did not require any special treatments, such as IV or oxygen, despite other information indicating oxygen therapy and respiratory treatments. Section Z of this quarterly MDS was signed by an RN on 12/23/2025, certifying completion of the assessment.

Additional documentation and interviews confirmed that the resident’s care needs had changed and were not reflected in a corresponding change in condition MDS. The care plan dated 01/14/2026 included problems and interventions such as cognitive loss, dietician referral, prescribed diet, altered nutritional status, shortness of breath, risk of dehydration, and oxygen therapy related to COPD, and noted that the resident recently received thin liquids and was progressing in speech. The CRN stated the resident had been hospitalized several times and returned with clinical changes including thickened liquids, respiratory treatments, and IV for enteral feeding, and acknowledged the need to check updated MDSs. The DON stated that MDS clinical assessments and plans should be updated to reflect the resident’s current status and that failing to complete or update MDS assessments placed the resident at risk of missing individualized clinical care, treatment, and tasks. The ADM reported that the facility had observed a pattern of failing to complete timely and accurate assessments and that the MDS coordinator had been terminated, and staff were unable to produce a change in condition MDS for this resident. The facility’s policy required comprehensive, accurate MDS assessments, coordinated and certified by an RN, and completed on admission, annually, quarterly, and within 14 days of a significant change, but this process was not followed for this resident’s change in condition.