Inaccurate BIMS Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medical records were complete and accurately documented for four of nine sampled residents, specifically in the completion of the Brief Interview for Mental Status (BIMS) section of the Minimum Data Set (MDS). The Long-Term Care Facility Resident Assessment Instrument (RAI) User’s Manual requires that Section C0100 be coded as 0 only if a resident is rarely/never understood, and coded as 1 with the BIMS completed if the resident is at least sometimes understood. Review of prior BIMS scores for these residents showed that they had consistently scored in the cognitively intact or mildly to moderately impaired ranges, with scores between 11 and 15 on multiple assessments throughout the previous year. On 1/19/26, an LPN (Employee E6) completed BIMS assessments for four residents and documented each as rarely/never understood, coding them as 0.0, indicating severe impairment, despite their prior documented BIMS scores of 11–15. Specifically, Resident R8 had prior BIMS scores of 14 and 15; Resident R18 had repeated scores of 15; Resident R46 had scores ranging from 11 to 15; and Resident R57 had repeated scores of 15. During an interview, the LPN confirmed that these residents were alert and oriented and acknowledged that the BIMS assessments completed on that date were done incorrectly. In a subsequent interview, the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to ensure that medical records for these residents were complete and accurately documented, in violation of 28 Pa. Code 211.5(f)(g)(h) regarding clinical records.
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.