Incorrect Coding of MDS Assessment for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for a resident with a history of schizophrenia, bipolar disorder, and cognitive communication deficit. The resident's clinical record included conflicting information: a Preadmission Screening and Resident Review (PASARR) indicated no known mental health conditions, while a resident information sheet reviewed by a physician listed schizophrenia and bipolar disorder as diagnoses. The admission MDS assessment did not indicate a diagnosis of schizophrenia, but a subsequent significant change in status MDS assessment did. Physician's orders did not include any antipsychotic medications for these conditions. Interviews with the Director of Nursing (DON) and the MDS Coordinator revealed that the diagnoses of schizophrenia and bipolar disorder were incorrectly entered into the MDS assessment, and these errors were later identified and removed. The facility did not have a specific MDS policy and relied on RAI guidelines.