Inaccurate MDS Assessment of Psychiatric Diagnoses
Penalty
Fine: $34,575
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 accurately reflect a resident's mental health diagnoses in the Minimum Data Set (MDS) assessment. Record review showed that the resident had documented diagnoses of anxiety disorder, major depressive disorder (recurrent, severe, without psychotic features), and post-traumatic stress disorder (PTSD) in the electronic health record. However, the most recent MDS assessment only marked PTSD under Section I: Active Diagnoses, omitting both anxiety disorder and depression. This discrepancy was confirmed during an interview with the Director of Nursing, who acknowledged the error.