Failure to Accurately Document Active Diagnosis of Depression in MDS Assessment
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for one resident by omitting depression as an active diagnosis in Section I, despite documentation in the medical record and ongoing treatment for depression. The resident's admission record and physician orders indicated a diagnosis of depression, and the resident was prescribed Trazadone for depression manifested by self-isolation. The MDS assessment, however, did not reflect depression as an active diagnosis, even though the resident was receiving antidepressant medication. During an interview and record review, the MDS nurse confirmed that the MDS was inaccurate and acknowledged that the resident had a diagnosis of depression based on the medical record. The facility's policy required healthcare professionals to certify the accuracy of the MDS, but this was not followed in this instance, resulting in an incomplete assessment for the resident.