Inaccurate MDS Assessment for Resident with Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) 3.0 assessment for one resident. The resident, who had a history of acute and chronic respiratory failure with hypoxia, type 2 diabetes, bipolar disorder, depression, PTSD, adjustment disorder with depressed mood, and ADHD, reported ongoing PTSD symptoms including nightmares, paranoia, and flashbacks. During interviews, the resident stated that staff had not questioned her about her PTSD. Review of her comprehensive MDS assessment showed that PTSD and bipolar disorder were not identified as diagnoses. The MDS nurse explained that these diagnoses were not coded because the resident was not believed to be on medications for them and only active diagnoses with medications are coded. However, review of physician's orders confirmed the resident was receiving psychotropic medications, including Cymbalta and Zoloft, as well as Melatonin. The MDS nurse later confirmed the assessment was not accurate.