Inaccurate MDS Assessment for Depression Diagnosis
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was completed accurately for one resident by not coding the resident's diagnosis of depression under MDS section I5800 (Active Diagnoses). The resident's admission record and history and physical indicated a diagnosis of depression, and the resident was prescribed Sertraline HCL, an antidepressant, for symptoms including crying, yelling, and self-biting. Despite this, the MDS assessment did not reflect the depression diagnosis, as confirmed by the MDS nurse during a review and interview. The resident was noted to have severely impaired cognitive skills and was totally dependent on staff for several activities of daily living. The facility's policy required staff completing any portion of the MDS to certify its accuracy, but this was not followed in this instance. As a result, incorrect data was transmitted to CMS, and the omission had the potential to affect the resident's plan of care and delivery of services.