Inaccurate MDS Assessment for Psychotropic Medication Use
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for a resident with multiple psychiatric diagnoses, including PTSD, anxiety, depressive disorder, obsessive-compulsive disorder, and dementia. The resident's annual MDS documented a Brief Interview for Mental Status (BIMS) score indicating intact cognition and a PHQ-9 score of zero, with no behaviors noted. The MDS also recorded that the resident was taking an antidepressant but inaccurately documented that no antipsychotic medication was administered, despite physician orders and care plans indicating otherwise. Further review of the resident's care plan and physician orders confirmed the use of antipsychotic medication, specifically Seroquel, for various psychiatric conditions. Interviews with nursing and administrative staff revealed an expectation that the MDS should have reflected the resident's antipsychotic medication use. The facility's policy requires comprehensive and accurate assessments using the Resident Assessment Instrument (RAI), but this was not followed, resulting in an incomplete and inaccurate assessment for the resident.