Inaccurate MDS Assessments for Diagnoses and Medication Use
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents, resulting in incorrect coding of active diagnoses and medication use. For one resident, the MDS assessment did not reflect active diagnoses of hypertension, hyponatremia, and depression, despite medical records and physician orders indicating these conditions. The assessment also failed to accurately document the use of antidepressant medication and incorrectly recorded the date of the last attempted gradual dose reduction (GDR) for antipsychotic medication. The MDS Coordinator confirmed these discrepancies, noting that some orders may have been carried over from a hospital stay without proper medical indication and that laboratory results were misinterpreted when coding the diagnosis of hyponatremia. Another resident's MDS assessments were also found to be inaccurate, as they did not include documented diagnoses of anxiety disorder and major depressive disorder, despite these being present in the resident's medical history and physician notes. The assessments showed the resident was cognitively intact but failed to code the relevant psychiatric diagnoses in Section I of the MDS. The MDS Coordinator acknowledged that these diagnoses should have been included as soon as they were documented by the physician or on the next assessment. Interviews with the MDS Coordinator, Administrator, and Director of Nursing confirmed the findings and acknowledged the inaccuracies in the MDS assessments. These failures had the potential to impact the provision of necessary care and services to meet the residents' needs, as the assessments did not accurately reflect their current medical conditions and medication use.