Failure to Accurately Reflect Depression Diagnosis in Resident Assessment
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected their current diagnoses. Specifically, a resident with a documented diagnosis of depression, as indicated on the face sheet and supported by ongoing physician orders for Buspirone and Escitalopram, did not have this diagnosis included on their quarterly Minimum Data Set (MDS) assessment. The resident's medication administration records confirmed that both medications for depression were being administered as ordered during the review period. Interviews with the MDS nurse and the Director of Nursing (DON) confirmed that the omission of the depression diagnosis from the MDS was an oversight. The facility's policy requires that comprehensive assessments include all disease diagnoses and history, but this was not followed in this instance, resulting in an inaccurate assessment for the resident.