Incomplete and Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed and accurate for three of four sampled residents reviewed for MDS discrepancies. For one resident, both the admission and quarterly MDS assessments remained in “In Progress” status as of the survey review. For a second resident, the annual MDS assessment and a significant change MDS assessment were also found in “In Progress” status. For a third resident, both the admission and quarterly MDS assessments were likewise in “In Progress” status. Medical record review and staff interview confirmed that these MDS assessments had not been updated, and the DON acknowledged that the assessments were incomplete. Facility policy on MDS 3.0 Completion, as provided by the DON, states that according to federal regulations the facility must conduct initially and periodically a comprehensive, accurate, and standardized assessment of each resident’s functional capacity using the RAI specified by the state. These findings show that required MDS assessments for multiple residents were not finalized as completed assessments in accordance with the facility’s own policy and federal requirements, resulting in inaccurate or incomplete resident assessments at the time of survey review.
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