Inaccurate MDS Assessments for Dental Status and Vascular Diagnoses
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents. For one resident, admission documentation showed she was admitted on an unspecified date, and during observation and interview she reported having several broken teeth that needed to be pulled. The surveyor observed broken teeth and discoloration of the upper and lower mouth. However, the resident’s admission MDS assessment documented that she was edentulous (lacking teeth). An LPN later observed the resident and confirmed she was not edentulous, and the DON acknowledged that the admission MDS inaccurately documented the resident as edentulous and that staff were expected to ensure MDS assessments were accurate. For another resident with a diagnosis of unspecified cerebral infarction, medical record review showed a CTA of the neck revealed complete occlusion of the right common carotid artery and greater than 70% stenosis of the left proximal internal carotid artery, with a recommendation for neurovascular evaluation. A provider progress note documented diagnoses of stenosis of the left internal carotid artery and occlusion of the right internal carotid artery, and that these serious findings and associated risks were discussed with the resident. Despite these documented diagnoses, the resident’s subsequent Quarterly MDS assessment did not include the CTA-related diagnoses in Section I (active diagnoses). The MDS coordinator stated she was unaware of these diagnoses, explained that the medical team liaison usually notifies her of new diagnoses, and acknowledged that the CTA findings should have been added to the resident’s MDS.
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