Failure to Accurately Reflect Active Diagnoses in MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the active diagnoses of two residents. For one resident, the MDS did not include a known diagnosis of post-traumatic stress disorder (PTSD), despite documentation in the resident's face sheet, care plan, and a progress note by a nurse practitioner confirming the diagnosis. The MDS nurse acknowledged uncertainty as to why the PTSD diagnosis was omitted and confirmed that all active diagnoses within the 7-day look-back period should be included in the MDS. The Director of Nursing (DON) was also unsure about the presence of a formal PTSD diagnosis but stated that if it existed, it should have been documented in the MDS. For another resident, the MDS assessment failed to reflect active diagnoses of depression and anxiety, even though the resident was prescribed and receiving anti-anxiety and antidepressant medications for these conditions. The care plan and order summary documented the use of medications such as Ativan, Buspar, and Citalopram for anxiety and depression. The MDS nurse stated she was responsible for ensuring the accuracy of MDS assessments and that diagnoses were added based on review of orders and medical records. The DON confirmed that psychiatric diagnoses related to psychotropic medication use should be included in the MDS. Facility policy required qualified health professionals to correctly document residents' medical, functional, and psychosocial problems.