Inaccurate MDS Assessment Documentation
Penalty
No penalty information released
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Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for a resident with multiple diagnoses, including cerebral palsy and major depressive disorder. Record review showed that the resident had physician orders and documentation for hydroxyzine, an anti-anxiety medication, as well as a diagnosis of severe, unspecified dementia. However, the resident's admission MDS did not indicate the presence of an anxiety disorder, the use of anti-anxiety medication, or a diagnosis of dementia. Staff interviews confirmed that the MDS assessments did not include these diagnoses or treatments, despite being documented in the resident's medical record.