Inaccurate MDS Assessments for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents with serious mental illness diagnoses. For one resident admitted after a fracture with diagnoses including bipolar disorder and generalized anxiety disorder, the medical record contained both a PASRR level I and an abbreviated PASRR level II screening, both identifying serious mental illness. However, the resident's Admission MDS Assessment incorrectly documented 'no' in section A1500, indicating the resident was not considered to have a serious mental illness or intellectual disability, despite the PASRR level II findings. Similarly, another resident with a diagnosis of bipolar disorder had a PASRR level I and an abbreviated PASRR level II screening, both confirming serious mental illness. While the MDS assessment initially reflected this, subsequent annual MDS assessments incorrectly marked 'no' in section A1500, failing to indicate the presence of a serious mental illness as determined by the PASRR level II screening. These inaccuracies were confirmed by the Regional MDS Nurse during staff interviews.