Failure to Accurately Code Active Mental Health Diagnoses in MDS Assessment
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for one resident out of sixteen reviewed. The resident in question was admitted with diagnoses including Type 2 Diabetes, Anxiety, Major Depressive Disorder, and Post-Traumatic Stress Disorder (PTSD). Documentation in the medical record, including a PASRR Level 2 outcome, indicated active mental health diagnoses and recommended ongoing psychiatric monitoring, nonpharmacological interventions, and close observation of moods and behaviors. Physician orders and care plans reflected ongoing monitoring and interventions for these mental health conditions, and the resident was prescribed medication for anxiety. Despite this, the quarterly MDS assessment did not document active diagnoses of PTSD, Anxiety, or Depression for the resident. Interviews with the MDS LPN and Clinical Reimbursement Specialist revealed a misunderstanding of what constitutes an active diagnosis, with both staff members stating that only residents receiving medication for a diagnosis should be considered as having an active diagnosis. The staff did not recognize that nonpharmacological interventions and nursing monitoring, as recommended in the PASRR and care plan, also indicated active diagnoses. As a result, the MDS assessment failed to accurately reflect the resident's current health status and active conditions.