Inaccurate MDS Assessment Due to Erroneous Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure that a resident received an accurate clinical assessment reflective of their actual status at the time of assessment. Specifically, the Minimum Data Set (MDS) assessments for the resident on two separate occasions documented an active medical diagnosis of schizophrenia. However, a review of the resident's electronic health record showed no diagnosis of schizophrenia, no documented behaviors, and no treatment orders related to schizophrenia. The resident's PASARR evaluation also indicated no mental illness, and behavioral care notes described diagnoses of major depressive disorder and dementia without behavioral or psychotic disturbances. Interviews with facility staff confirmed that the resident did not have any orders for psychotropic medications and did not exhibit behaviors indicative of schizophrenia. The MDS-Registered Nurse acknowledged that the schizophrenia diagnosis was entered in error on multiple MDS assessments. This inaccurate documentation resulted in the resident's clinical status being misrepresented in official records.