Inaccurate and Incomplete Quarterly MDS Assessment for ADL Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s quarterly Minimum Data Set (MDS) assessment accurately reflected her functional status and care needs. The quarterly MDS, completed by an LVN, did not properly address the resident’s Safety and Quality of Performance in multiple Activities of Daily Living (ADLs), including eating, oral hygiene, toileting hygiene, shower/bathing, upper and lower body dressing, putting on/taking off footwear, and personal hygiene, and did not indicate the type of wheelchair or scooter used. The resident was an elderly female with a BIMS score of 03, indicating severe cognitive impairment, and her physician orders included the use of geri sleeves to both upper extremities every shift. Her quarterly care plan documented an ADL self-care performance deficit, risk for not having needs met in a timely manner, and risk for emotional distress, and specified that she required assist of one person for personal hygiene and bathing, along with scheduled and as-needed grooming and hygiene care and encouragement to use the call light for assistance with ADLs. Interviews with facility leadership confirmed that the incomplete and inaccurate MDS had not been identified or corrected. The ADON stated she was not aware that the resident’s MDS did not address her functional abilities and contained incomplete sections, and acknowledged that timely completion of the MDS was important because it reflected the resident’s daily care and needs to maintain the highest level of care. The DON stated it was her expectation that MDS staff conduct timely, comprehensive quarterly assessments to address the resident’s current status of care and prevent decline, and that it was the responsibility of the DON and MDS staff to ensure MDS assessments were completed comprehensively. The facility’s Clinical Practice Guidelines for MDS Completion required residents to be assessed using a comprehensive assessment process to identify care needs and develop an interdisciplinary care plan, with quarterly assessments completed within the required timeframe, but this process was not followed for the resident’s quarterly MDS.
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.