Failure to Accurately Document Parkinson's Disease in MDS Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's active diagnosis of Parkinson's disease. Despite documentation in the resident's admission record, physician orders, and neurology consultation notes indicating a diagnosis of Parkinson's disease and ongoing treatment with Sinemet, the MDS did not include Parkinson's disease under the active diagnoses section. The resident was observed to have symptoms consistent with Parkinson's, such as noticeable tremors, and was able to verbally confirm the diagnosis. A review of medication administration records further confirmed that the resident was receiving Sinemet for Parkinson's disease, with periods of discontinuation and restart as ordered by the neurologist. During interviews, the LVN responsible for the MDS assessment was unable to explain why Parkinson's disease was omitted from the MDS and acknowledged the inaccuracy. The neurologist who evaluated the resident noted that follow-up was not conducted by the facility after initiating a Levodopa trial, despite instructions to monitor for adverse reactions. The facility's policy requires that MDS assessments consistently reflect information from progress notes, care plans, and resident observations, which was not followed in this case, resulting in an inaccurate assessment entry for the resident.