Failure to Accurately Complete MDS Assessment for Serious Mental Illness
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for one resident by not identifying that the resident had a serious mental illness as determined by the state Level II Preadmission Screening and Resident Review (PASRR). Clinical record review showed that the resident's MDS, dated 3/22/25, listed diagnoses of psychotic disorder, anxiety disorder, and depression, but did not indicate that the resident was considered to have a serious mental illness by the PASRR process. However, the resident's PASRR Level II outcome, dated 1/20/24, confirmed that the resident met criteria for serious mental illness due to a diagnosis of major depressive disorder. Facility policy required accurate assessment and documentation of residents' medical, functional, and psychosocial problems. The Corporate Nurse confirmed the expectation that the MDS should be completed accurately.