Failure to Accurately Complete MDS Assessment for Active Diagnosis
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for a resident by omitting an active diagnosis of schizophrenia in Section I of the assessment, despite clear documentation of this diagnosis in the resident's medical record. The resident's admission record, history and physical, psychiatric note, and order summary all indicated a diagnosis of schizophrenia, with associated behaviors such as confabulation and uncontrollable yelling, and a prescription for Zyprexa specifically for this condition. However, the MDS assessment did not reflect this diagnosis. During an interview, the DON acknowledged that the MDS assessment was inaccurate and attributed the omission to an oversight by the MDS coordinator. Facility policy requires that MDS assessments consistently reflect information found in progress notes, care plans, and resident observations. The failure to include the schizophrenia diagnosis in the MDS assessment meant that the resident's assessment did not accurately represent his current status as required by both facility policy and regulatory standards.