Failure to Accurately Complete and Submit MDS Assessment
Penalty
Summary
The facility failed to complete and submit a comprehensive Minimum Data Set (MDS) assessment for a resident within the required federal timeframe. Upon review, it was found that the resident, who had diagnoses including anoxic encephalopathy, dementia, hypertension, depression, anxiety, insomnia, and dysphagia, was admitted with these conditions documented in the admission record. However, the MDS assessment did not accurately reflect the resident's current diagnoses, specifically omitting depression and dementia, despite the resident being prescribed a psychotropic medication for behavioral and psychological symptoms of dementia. Interviews with the LVN responsible for MDS completion and the Director of Nursing confirmed that the assessment was not completed accurately or in accordance with facility policy and federal requirements. The facility's policy required timely and accurate completion and electronic submission of the MDS, but this process was not followed. As a result, the resident's progress or decline was not adequately monitored, and accurate, resident-specific information was not submitted to CMS for payment and quality measure monitoring.