Inaccurate MDS Assessments for Mental Illness and Hospice Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the clinical status of two residents. For one resident, the diagnosis list indicated bipolar disorder and a Level II PASARR assessment confirmed criteria for severe mental illness. However, the significant change MDS did not correctly indicate the resident's PASARR status, marking that the resident had not been evaluated for serious mental illness, despite documentation to the contrary. This discrepancy was acknowledged by nursing staff, who confirmed the error in MDS coding. For another resident, the significant change MDS assessment failed to identify that the resident was on hospice care, despite medical records and care plans clearly documenting hospice admission and related interventions. Previous MDS assessments had correctly indicated hospice status, but the most recent significant change assessment omitted this information. The DON confirmed that the MDS did not accurately reflect the resident's hospice status.