Inaccurate MDS Assessments for Resident with Psychiatric and Substance Use History
Penalty
Summary
The facility failed to ensure that both the admission and Quarterly Minimum Data Set (MDS) assessments accurately reflected a resident's clinical status. Specifically, the MDS assessments did not include the resident's diagnoses of PTSD, history of suicidal behaviors, suicidal ideations, or substance use/abuse, despite these being documented in the resident's medical record and social services assessments. The resident's admission and Quarterly MDS both recorded a BIMS score indicating intact cognition and omitted critical psychiatric and substance use diagnoses. Interviews with facility staff confirmed that the resident's social services history and initial assessment identified PTSD, increased anxiety, and a history of substance use/abuse, but these were not reflected in the MDS assessments. The omission was acknowledged by both the Social Services Director and the Administrator, who confirmed that the relevant diagnoses and history should have been included in the MDS documentation.