C0820

Inaccurate MDS Assessment of Resident's Hearing Status

Redding Post AcuteRedding, California Survey Completed on 10-22-2025

Summary

The facility failed to ensure the accuracy of the admission Minimum Data Set (MDS) for one resident when the MDS indicated the resident had no hearing difficulty, despite multiple sources indicating otherwise. Documentation in the resident's referral packet, discharge summary, and initial assessments by the activities director and speech therapist all noted that the resident was hard of hearing or had trouble hearing out of the right ear. The MDS Coordinator confirmed that the admission MDS inaccurately reflected the resident's hearing status as having no difficulty, despite evidence from the speech therapy evaluation and activities assessment indicating otherwise.

Interviews with the resident's family member and facility staff revealed that there was no visible indication in the resident's room about the hearing impairment, and staff did not appear to be aware of the resident's hearing difficulties. The MDS Coordinator acknowledged that the information used to complete the MDS should have included input from various assessments and documentation, which would have shown the resident was hard of hearing. The failure to accurately assess and document the resident's hearing status on the admission MDS was confirmed through record review and staff interviews.

Penalty

No penalty information released