Failure to Accurately Code Schizophrenia Diagnosis on MDS Assessment
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) assessment was accurately completed for a resident with a diagnosis of schizophrenia. The resident, who was admitted with multiple diagnoses including schizophrenia, had this condition documented in their admission record and in several psychiatrist assessments. However, the quarterly MDS assessment did not reflect the active diagnosis of schizophrenia, despite ongoing evaluation and monitoring for the condition by psychiatric staff. During interviews and record reviews, the MDS nurse acknowledged that the resident's schizophrenia should have been coded as an active diagnosis on the MDS assessment. The Interim Director of Nursing confirmed that the facility's policy requires assessments to accurately reflect the resident's status and stated that this policy was not followed in this instance. The omission resulted in the resident's MDS assessment not accurately representing their care and support needs.