State Findings:
Based on record review and interviews, the facility failed to ensure the minimum data set assessment (MDS) accurately reflected residents’ status for three (#4, #7 and #25) of 12 out of 24 sample residents.
Specifically, the facility failed to appropriately assess, according to the Resident Assessment Instrument (RAI):
-Cognitive patterns, mood and behavior for Resident #4;
-Health conditions for Resident #7; and,
-Functional status and health conditions for Resident #25.
Record review
The 1/2/22 minimum data set (MDS) assessment revealed in section B, the resident had clear speech, made self-understood and was able to understand others.
Section C (Cognitive Patterns) was not completed, not assessed.
Section D (Mood) was not completed, not assessed.
Section E (Behavior) was not completed, not assessed.
Resident #4 medical record review revealed no documentation related to the lack of appropriate completion of sections C, D and E of the MDS assessment.
The facility failed to ensure Resident #4’s mental and psychosocial status assessment reflected an accurate picture of the resident’s status during the observation period of the MDS.
The 10/16/21 MDS assessment revealed the resident’s cognition was intact with a brief interview for mental status (BIMS) score 14 out of 15. No rejection of care behavior. He required extensive assistance of two staff with bed mobility and transfers, extensive assistance of one person with dressing, eating, toilet use, and limited assistance with personal hygiene. He had an indwelling urinary catheter. Section J (Health Conditions) revealed the resident received scheduled pain medications and the pain assessment interview should be conducted.
The pain assessment part in this section was not completed, not assessed.
Review of the current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order date was 3/17/21.
The 7/16/21 MDS assessment (Section J) revealed the pain assessment interview was not completed, not assessed.
The 4/15/21 MDS assessment (Section J) revealed the pain assessment interview was not completed, not assessed.
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