Inaccurate MDS Assessment Documentation
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status. Specifically, for one resident admitted with multiple diagnoses including spina bifida, anxiety, major depression, and PTSD, the admission MDS assessment did not document the presence of PTSD in Section I, despite the resident having this diagnosis. Record review and staff interview confirmed that PTSD should have been included in the assessment, but it was omitted. This inaccuracy was identified during a review of the resident's records and through an interview with the Social Services Supervisor, who acknowledged the omission.