Inaccurate MDS Assessment Due to Miscoded Diagnosis
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected the resident's active diagnoses. Specifically, the MDS assessment for one resident incorrectly included a diagnosis of schizophrenia, despite the absence of supporting documentation in the resident's medical record and physician orders. The resident's medical history included dementia with psychotic disturbance, neurosyphilis, and depressive episodes, but not schizophrenia. The error was identified during a review of the resident's face sheet, care plan, and physician orders, which did not list schizophrenia as an active diagnosis. Interviews with facility staff revealed that the MDS Coordinator, who was responsible for assessments at two facilities and often worked remotely, miscoded the diagnosis, possibly due to confusion with another resident with a similar last name. The incorrect diagnosis of schizophrenia was first entered in a previous assessment and subsequently carried over to later assessments. The facility's policy requires that MDS assessments accurately reflect each resident's status, but this was not followed in this instance, resulting in an inaccurate assessment for the resident.