Inaccurate MDS Assessment Documentation for PTSD Diagnosis
Penalty
No penalty information released
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Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status. Specifically, a resident admitted with multiple diagnoses, including emphysema, anxiety, and post-traumatic stress disorder (PTSD), had PTSD documented on both Level I and Level II PASRR assessments. However, multiple MDS assessments for this resident did not indicate PTSD under the relevant section. The Director of Nursing confirmed that PTSD should have been documented in each MDS once it was listed on the PASRRs, but it was not. This discrepancy was identified through observation, interview, and record review.