Failure to Accurately Code Schizophrenia Diagnosis in MDS
Penalty
Summary
The facility failed to accurately code a resident's diagnosis of schizophrenia in the Minimum Data Set (MDS), despite the diagnosis being documented in the resident's medical record. The resident was admitted and readmitted with multiple diagnoses, including schizophrenia, as indicated in the History and Physical (H&P) dated after the most recent admission. However, review of the MDS showed that the checkbox for schizophrenia under the psychiatric/mood disorders section was not marked, resulting in the resident's MDS not reflecting the current diagnosis. Interviews with the MDS Coordinator confirmed that the diagnosis of schizophrenia was present in the medical record and should have been coded on the MDS to accurately represent the resident's condition. The Director of Nursing also acknowledged the importance of accurate coding for care planning and treatment. The omission was identified through record review and staff interviews, and it was noted that failure to code an active diagnosis can result in inaccurate assessments and improper care planning, as referenced in the CMS RAI User's Manual.
Plan Of Correction
F-tag: 640 Encoding/Transmitting Resident Assessments Immediate corrective actions: On 4/29/2025, MDS Coordinator conducted a meeting with the IDT team and psychiatrist to clarify Resident 15's diagnosis of Schizophrenia. On 4/29/2025, MDS Coordinator modified Resident 15's MDS to reflect current diagnosis of Schizophrenia. On 5/2/2025 & 5/23/2025, DON & MDS Consultant provided in-service/training and re-education to MDS/Designee with emphasis on accuracy of encoding/transmission of assessment. Identification of others at risk: On 05/02/2025, the MDS reviewed clinical records of active residents with diagnosis of Schizophrenia. No other residents were identified with the same deficient practice. Process to prevent recurrence: On 05/02/25 and 05/20/25, the DON provided inservices/retraining to MDS staff (LVN, RN) to reinforce policy on accuracy of coding in MDS and transmission assessment. Monitoring process: The MDS consultant will review MDS of 5 residents with current diagnosis of Schizophrenia x 3 months to ensure accuracy of coding in the MDS. DON will report MDS findings to the QAPI committee monthly for further recommendations, resolution, and follow-up. Completion date: 5/23/2025 NotSpecified