Incomplete MDS BIMS Section for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure an accurate and complete Minimum Data Set (MDS) assessment for one resident. Record review showed that this resident was admitted with diagnoses including unspecified dementia with behavioral disturbance and unspecified symptoms and signs involving cognitive functions and awareness. Review of the resident’s MDS, dated as noted in the record, showed that staff indicated a Brief Interview for Mental Status (BIMS) should be conducted, but no answers were documented in the BIMS section. In an interview, the MDS Coordinator confirmed she was responsible for completing this resident’s MDS assessments and stated that her expectation was that the assessments be fully completed and that staff should not leave sections unanswered. This deficient practice could result in failure to provide adequate care and treatment of the resident's needs.
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