Failure to Accurately Document Resident Diagnoses in MDS Assessment
Penalty
No penalty information released
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Summary
The facility failed to accurately document and submit a complete Minimum Data Set (MDS) assessment for one resident. Clinical record review and staff interviews revealed that the MDS assessment for this resident recorded a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition, and included diagnoses of anxiety, depression, and bipolar disorder. However, the MDS did not include a diagnosis of Post Traumatic Stress Disorder (PTSD), despite both the initial and current psychiatric progress notes documenting PTSD as a diagnosis. The administrator confirmed that Social Services should have reviewed the psychiatric notes to ensure all correct diagnoses, including PTSD, were reflected in the MDS.