Inaccurate Schizophrenia Diagnosis Documented on MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident received an accurate clinical assessment reflective of their current status, resulting in an inaccurate diagnosis of schizophrenia being documented on the Minimum Data Set (MDS) assessment. The MDS for the resident indicated an active diagnosis of schizophrenia, despite no evidence of psychosis-related behaviors during the assessment period and no treatment or prescription of antipsychotic medication for schizophrenia while at the facility. The resident's medical diagnosis list included schizophrenia, but this was based on a historical entry and not on current clinical findings. Interviews with facility staff confirmed that the resident was not being treated for schizophrenia and had no related behaviors observed. The social worker stated that the resident's depression medication was managed by a psychiatrist, but there was no treatment for schizophrenia. The MDS nurse acknowledged that the resident was coded as having schizophrenia on the MDS, despite the absence of supporting clinical evidence or treatment. Review of the MDS 3.0 RAI manual emphasized the requirement for accurate assessments based on validated information from the observation period, which was not met in this case.