Inaccurate MDS Assessment Entry for Resident Diagnosis
Penalty
Summary
The facility failed to ensure the accuracy of assessment entries for a resident by incorrectly documenting a diagnosis of schizophrenia on the Minimum Data Set (MDS) without sufficient supporting documentation. The resident, who had a history of chronic pulmonary edema, atrial fibrillation, and anxiety disorder, was assessed as having severely impaired cognitive skills for daily decisions. However, the MDS included an active diagnosis of schizophrenia, which was not substantiated by the resident's medical records or behavioral observations. Interviews with the MDS nurse revealed that the schizophrenia diagnosis was entered in error, as there was no documentation meeting DSM-V criteria to support it. The Director of Nursing confirmed that a proper diagnosis requires supporting documentation from a medical professional, which was not present in this case. Facility policy requires the interdisciplinary team to conduct accurate and timely assessments using the MDS and other relevant forms, but this process was not followed for the resident in question.