Inaccurate MDS Assessment and Documentation
Penalty
Summary
The facility failed to ensure that a resident's health status was accurately documented on the admission Minimum Data Set (MDS). Specifically, the MDS sections regarding active diagnoses and fall history did not accurately reflect the resident's condition. The MDS indicated that the resident had not experienced a fall or sustained a fracture related to a fall in the months prior to admission, despite the admission record showing diagnoses of bilateral calcaneus fractures. Additionally, the MDS listed schizophrenia as an active diagnosis, although the psychiatric discharge note and health and physical did not support this diagnosis, instead documenting psychosis, anxiety disorder, and opiate dependency. Interviews with the MDS Coordinator and review of the resident's Medication Administration Record confirmed that the MDS was completed with incorrect information. The MDS Coordinator acknowledged that the fall history questions were answered incorrectly and that schizophrenia was selected as an active diagnosis based on a history rather than current documentation or treatment. Review of the CMS Resident Assessment Instrument manual with facility staff further confirmed that only active diagnoses with direct relevance to current treatment during the look-back period should be included, and that the documentation did not support the inclusion of schizophrenia as an active diagnosis.