Failure to Accurately Document PTSD Diagnosis in MDS Admission Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) comprehensive assessment accurately identified all current diagnoses for a resident upon admission. Specifically, a resident admitted with diagnoses of unspecified dementia, anxiety disorder, and post-traumatic stress disorder (PTSD) did not have PTSD documented in Section I of the MDS admission assessment. The assessment, completed on 03/18/2025, only listed non-Alzheimer's dementia and anxiety as current diagnoses, omitting PTSD despite it being part of the resident's medical history. Interviews with facility staff revealed that the omission occurred because the MDS coordinator did not include PTSD in the assessment, relying instead on the timing of the resident's appointment with a mental health provider, which took place after the MDS was completed. The lead MDS coordinator confirmed that PTSD should have been included in the admission assessment, as the diagnosis was already established at the time of admission.