Failure to Accurately Document Anti-Psychotic Medication Use in MDS
Penalty
Summary
The facility failed to ensure that the use of an anti-psychotic medication was accurately documented in the Minimum Data Set (MDS) for one resident. Review of the resident's records showed that the resident had diagnoses including bipolar disorder, schizoaffective disorder, and heart failure, and was prescribed Risperdal, an anti-psychotic medication, for schizoaffective disorder. However, the MDS assessment did not indicate that the resident was taking any anti-psychotic medication. During an interview and record review with the MDS Nurse, it was confirmed that the MDS did not reflect the resident's use of Risperdal. The MDS Nurse acknowledged that Risperdal is an anti-psychotic and stated the importance of accurate MDS documentation, as this information is submitted to CMS and is used to guide the resident's plan of care and quality of care.