Inaccurate MDS Assessments for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents. For one resident with diagnoses including PTSD, major depressive disorder, and anxiety, the PASRR Level II assessment documented a serious mental illness, but the admission and quarterly MDS assessments did not indicate this diagnosis under the relevant sections. Specifically, the MDS did not reflect the PTSD diagnosis and incorrectly marked that the resident was not considered to have a serious mental illness by the PASRR process. For another resident with major depressive disorder and orthopedic conditions, the admission MDS assessment also failed to indicate that the resident was considered by the PASRR Level II process to have a serious mental illness. These inaccuracies were confirmed during staff interviews, where it was acknowledged that the MDS assessments should have been completed differently to accurately reflect the residents' diagnoses and PASRR determinations.