Failure to Accurately Code PTSD Diagnosis on MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's status was accurately identified on the Minimum Data Set (MDS) assessment. Specifically, a resident with documented diagnoses of major depressive disorder and post traumatic stress disorder (PTSD) was not coded for PTSD on the quarterly MDS assessment, despite this diagnosis being present on the resident's face sheet and care plan. The care plan included interventions related to trauma responses, such as ensuring clear paths to doors and honoring the resident's preferences regarding door positions, which were observed being implemented during facility activities. Interviews with facility staff revealed that the clinical reimbursement manager did not mark PTSD on the MDS because it was not documented in the most current provider note, even though the diagnosis was active in the last 60-day provider note and the care plan had active interventions for PTSD. The administrator indicated there had been previous efforts to ensure only documented active cases were marked on the MDS, but acknowledged the need to review this process. Facility policy requires that assessments accurately reflect the resident's status and that staff certify the accuracy of their portions of the assessment.