Inaccurate MDS Assessment Coding for Resident with Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for one resident. The resident, a 71-year-old individual with multiple diagnoses including unspecified atrial fibrillation, type 2 diabetes mellitus, edema, osteoarthritis, obesity, venous insufficiency, and psychiatric/mood disorders, had an MDS annual assessment completed with discrepancies. Specifically, Section A1500 of the MDS, which addresses the Preadmission Screening and Resident Review (PASRR), was marked as 'No' for serious mental illness or intellectual disability, despite the resident having active diagnoses of bipolar disorder, psychotic disorder, and schizophrenia as indicated in Section I of the same assessment. Interviews revealed that the LPN responsible for MDS at the time of the survey was not the one who completed the July MDS and was not employed at the facility during that period. The LPN acknowledged that Section A1500 was not documented appropriately. The facility administrator confirmed there was no specific policy for accurately completing MDS assessments and stated that staff are expected to follow the RAI Manual for guidance.