Inaccurate MDS Documentation for Residents with Serious Mental Illness
Penalty
Summary
Surveyors identified that the facility failed to ensure accurate and complete assessments for residents with serious mental illness, as required by regulatory standards. Multiple residents with diagnoses such as bipolar disorder, schizophrenia, major depression, anxiety, and psychotic disorders had Preadmission Screening and Resident Review (PASRR) Level I and II screenings indicating the presence of serious mental illness. However, these findings were not accurately documented in Section A1500 of the Minimum Data Set (MDS) assessments. In several cases, the MDS assessments incorrectly indicated that the residents did not have a serious mental illness, despite clear evidence from PASRR screenings and medical diagnoses. Interviews with facility staff, including social workers and the Director of Nursing, confirmed that the MDS assessments were coded incorrectly for these residents. Staff acknowledged the errors when questioned by surveyors, and no additional explanations were provided for the inaccuracies. The deficiencies were observed for all reviewed residents with serious mental illness and PASRR screenings, indicating a pattern of inaccurate documentation in the residents' comprehensive assessments.