Inaccurate MDS Assessments for Weight Loss and Mental Illness Diagnosis
Penalty
Summary
The facility failed to submit accurate information on the Comprehensive Minimum Data Set (MDS) assessments for two residents. For one resident, the MDS assessment did not accurately reflect a significant weight loss of 10% or more over the previous six months, as documented in the electronic health record (EHR). The MDS recorded the resident's weight and indicated no significant weight loss, despite EHR documentation showing a decrease from 272 pounds to 235 pounds over the relevant period. The MDS Coordinator acknowledged that the weight loss section was incorrectly answered and that the resident was on a physician-prescribed weight loss regimen. For another resident, the MDS assessment failed to accurately report the presence of a serious mental illness as determined by the PASRR Level II screening. Although the EHR and PASRR documentation confirmed a diagnosis of bipolar disorder, the MDS incorrectly indicated that the resident did not have a serious mental illness. The MDS Coordinator confirmed that the relevant section of the MDS was answered incorrectly, contrary to the guidance provided in the 2024 Resident Assessment Instrument (RAI).