Inaccurate Resident Assessment for Medication Management
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for one resident reviewed for medication management. The resident was admitted with diagnoses including dementia, major depressive disorder, and an anxiety disorder, as documented in the admission record and physician orders. Despite these diagnoses and corresponding physician orders for psychiatric evaluation and medication for anxiety, the Minimum Data Set (MDS) assessment did not include anxiety disorder under Section I-Active Diagnoses. The MDS Coordinator confirmed that the medication section indicated anxiety and depression, but the anxiety diagnosis was not included in the MDS because it was attached to the dementia diagnosis and did not transfer over. The Director of Nursing stated that the facility follows the RAI manual.