Inaccurate MDS Assessment for Resident with Behavioral and Mental Health Concerns
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident with a diagnosis of depression. The resident's MDS assessment did not reflect any behavioral concerns, physical or verbal inappropriate behaviors, suicidal or homicidal ideations, or rejection of care. However, multiple other records, including the care plan, nurse progress notes, and a change in condition form, documented that the resident exhibited drug-seeking behavior, hypersexuality, verbally abusive behavior, and both suicidal and homicidal ideations. The care plan specifically noted risks related to these behaviors, and nurse progress notes described the resident expressing feelings of depression, danger to self, and explicit statements about suicidal and homicidal thoughts. Further documentation included a change in condition form noting behavioral symptoms and depression, as well as interviews with the resident, DON, and Administrator confirming ongoing behavioral and mental health concerns. The resident himself reported ongoing suicidal thoughts and a desire to end his life, while facility leadership acknowledged issues with aggressive, inappropriate, and drug-seeking behaviors. Despite this, the MDS assessment failed to capture these significant behavioral and mental health issues, resulting in an inaccurate assessment.