Inaccurate MDS Assessment for Antidepressant Use
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for a resident with diagnoses of schizophrenia, anxiety, and delusional disorders. The resident's electronic medical record showed an active physician's order for Paxil, an antidepressant, prescribed for anxiety. During the assessment period for the Quarterly MDS, the resident received this antidepressant medication. However, the MDS inaccurately documented that the resident did not receive antidepressant medications during the observation period. This inaccuracy was confirmed by an administrative nurse, who acknowledged that the Quarterly MDS did not reflect the resident's actual medication administration. The facility reported using the Resident Assessment Instrument (RAI) for MDS completion but did not provide a policy regarding this process. The inaccurate documentation could result in unidentified care needs for the resident.