Failure to Accurately Identify Resident Diagnosis in MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's status was accurately identified in the Minimum Data Set (MDS) assessment. Specifically, a resident with documented diagnoses of post-traumatic stress disorder (PTSD), anxiety, and depression, as indicated in the Preadmission Screening Results and medical diagnosis list, did not have PTSD identified on the admission MDS assessment. Subsequent quarterly and significant change MDS assessments did include the PTSD diagnosis. The assistant director of nursing confirmed that the admission MDS, completed by contracted staff, lacked the PTSD diagnosis, which would have triggered care planning for PTSD to ensure appropriate support. The Resident Assessment Instrument (RAI) manual requires that MDS submissions be accurate and reflect the resident's actual condition during the look-back period.