Inaccurate MDS Assessment for Depression Diagnosis
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected the resident's diagnosis of depression. The resident, who had a history of psychosis, dementia, and schizophrenia, was readmitted to the facility with documented diagnoses that included major depressive disorder. Medical records, including a psychiatric evaluation and physician orders, indicated the resident was prescribed bupropion, an antidepressant, specifically for depression. Despite this, the MDS assessment did not include depression as an active diagnosis. During an interview and record review, the MDS Coordinator confirmed that the omission of the depression diagnosis from the MDS was an error, acknowledging that the resident's use of antidepressant medication and documented diagnosis warranted its inclusion. The facility's policy requires comprehensive and accurate assessments to guide care planning, but this was not followed in this instance, resulting in an incomplete assessment for the resident.