Inaccurate MDS Assessment Due to Omitted BIMS Evaluation
Penalty
Summary
The facility failed to complete an accurate MDS assessment for one resident when the Brief Interview for Mental Status (BIMS) was not conducted as required. The resident had been admitted with multiple diagnoses, including age-related osteoporosis without current pathological fracture, epileptic spasms without status epilepticus, GERD without esophagitis, hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, unspecified insomnia, recurrent moderate major depressive disorder, and a need for assistance with personal care. Record review showed that on a prior MDS dated 09/16/25, the resident’s BIMS score was documented as 15, indicating that a cognitive assessment had been completed at that time. However, review of the subsequent MDS dated 12/17/25 revealed that the resident was not assessed for BIMS at all. During an interview, the MDS coordinator confirmed that this assessment did not include an in-person evaluation and acknowledged that the MDS was completed remotely for this particular assessment. She further confirmed that the omission of the BIMS assessment made the MDS inaccurate, as the resident should have been assessed in person and the BIMS completed as part of the federally mandated assessment process.
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