Inaccurate MDS Assessment for Resident with PASRR Level II Status
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for one resident who was reviewed for MDS assessments. Specifically, a resident with a documented PASRR Level II outcome for serious mental illness, including diagnoses of Bipolar Disorder, Depression, and Anxiety, was not accurately coded for their PASRR Level II status on a significant change MDS assessment. The PASRR Level II screening had been completed prior to admission and indicated the need for certain care and services related to serious mental illness. Despite the resident's medical record and psychiatric notes confirming ongoing diagnoses of Bipolar Disorder and Anxiety, the significant change MDS assessment did not reflect the resident's PASRR Level II status. During a review and interview, the RN MDS Coordinator acknowledged the inaccuracy in the assessment. The facility's policy and federal regulations require accurate and comprehensive assessments using the RAI process, but this was not followed in this instance.