Failure to Accurately Code PTSD Diagnoses in Resident Assessments
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current diagnoses of two residents with Post-Traumatic Stress Disorder (PTSD). Review of the clinical records for both residents showed that each had an active diagnosis of PTSD upon admission. However, examination of their respective Quarterly Minimum Data Set (MDS) assessments revealed that the PTSD diagnosis was not marked as present in Section I: Active Diagnoses. During interviews, the staff member responsible for completing the MDS assessments confirmed that the PTSD diagnosis should have been indicated for both residents but was not. The Director of Nursing stated that MDS nurses are expected to complete assessments that accurately reflect each resident's active diagnoses and current status.