Failure to Accurately Code MDS for Serious Mental Illness
Penalty
Fine: $14,015
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for one resident. Record review and staff interview revealed that a resident with diagnoses of bipolar disorder, Tourette's disorder, and autistic disorder was not coded for serious mental illness in Section A1500 of the comprehensive MDS, as required by the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual. An administrative nurse confirmed that staff did not accurately code this section for the resident, resulting in the resident's assessment not reflecting their current status and needs.