Inaccurate MDS Diagnosis Entry Due to Lack of Supporting Documentation
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by inaccurately documenting a resident's diagnosis in the Minimum Data Set (MDS). Specifically, a resident with a history of chronic pulmonary edema, atrial fibrillation, and anxiety disorder was incorrectly assessed as having an active diagnosis of schizophrenia on the MDS. This entry was made without sufficient supporting documentation or evidence that the resident met the diagnostic criteria for schizophrenia as outlined in the DSM-V. The MDS nurse acknowledged that the documentation did not support the diagnosis and that the resident did not exhibit symptoms such as hallucinations or delusions. Interviews with facility staff, including the MDS nurse and the Director of Nursing (DON), confirmed that the required criteria and supporting documentation for a schizophrenia diagnosis were not present. The DON stated that a medical professional's documentation is necessary before such a diagnosis can be recorded in the MDS. The facility's policy requires the interdisciplinary team to conduct accurate and appropriate resident assessments using the MDS, but this process was not followed in this instance, resulting in an inaccurate assessment entry for the resident.