Failure to Accurately Document Mental Illness in MDS Assessments
Penalty
Summary
The facility failed to ensure that resident status was accurately identified in the Minimum Data Set (MDS) assessments for two sampled residents. For one resident, documentation showed diagnoses of altered mental status, social phobia, depression, hallucinations, and psychotic disorder with delusions. This resident's Level I PASRR indicated a referral for a Level II assessment for mental illness, which was completed and confirmed the presence of mental illness. However, the resident's admission MDS and subsequent MDS assessments did not document the mental illness in Section A, despite the PASRR findings. Interviews with the social worker revealed that the omission occurred because the resident was not eligible for additional services, but the social worker acknowledged that the MDS should have been coded to reflect the mental illness diagnosis. The DON also agreed that the MDS should accurately reflect the resident's condition. Review of the facility's policy showed requirements for timely completion of assessments but did not specify procedures to ensure accuracy, staff training, or oversight for MDS completion.