Inaccurate MDS Assessment Due to Unsupported Mental Health Diagnosis
Penalty
No penalty information released
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 complete Minimum Data Set (MDS) assessments that accurately reflected a resident's mental health diagnoses. Specifically, a resident admitted with major depressive disorder and schizophrenia had schizophrenia coded in Section I of both the admission and quarterly MDS assessments. However, upon review, the Director of Nursing Services (DNS) confirmed there was no supporting evidence in the medical record for the diagnosis of schizophrenia, and acknowledged that the MDS should not have been coded with this diagnosis in the absence of documentation. This resulted in an inaccurate assessment for the resident.