Inaccurate and Incomplete MDS Cognitive Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) assessments accurately reflected resident status, particularly in the area of cognitive assessment. Surveyors’ review of MDS records showed that multiple residents had assessments in which the Brief Interview for Mental Status (BIMS) or Section C (cognitive patterns) was coded as “not assessed” or left incomplete without documentation that the interview could not be completed. One resident’s quarterly assessment, another resident’s annual assessment, and a third resident’s comprehensive admission assessment all documented the BIMS as not assessed. Another resident’s admission assessment showed Section C as not assessed, and a further admission assessment documented Section C as not assessed despite indicating the resident should have been interviewed. Two quarterly assessments for another resident also documented the BIMS as not assessed. During interviews, the Regional Social Worker stated that if interviews were not completed within the look-back period, the assessment would be coded as not assessed. The DON reported being unaware that sections of assessments were incomplete. In a joint interview with the Administrator, DON, and Regional Administrator, the Administrator stated they did not know why assessments were missing information and acknowledged that incomplete assessments had not been identified through the facility’s Quality Assurance and Performance Improvement (QAPI) process. The MDS Coordinator was unavailable for interview during the recertification survey. These findings were cited under 10 New York Codes, Rules and Regulations 415.11(a)(1).
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