Failure to Accurately Document Active Diagnosis in MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected her current diagnoses. Specifically, a quarterly Minimum Data Set (MDS) assessment did not include a diagnosis of Anxiety for a female resident who had a documented history of Anxiety Disorder, as well as other conditions such as Unspecified Dementia, Type 2 Diabetes Mellitus, Muscle Weakness, Hypertension, and Major Depressive Disorder. The resident was actively receiving Buspirone, an anti-anxiety medication, as ordered by her physician, and this was reflected in both the physician order summary and the medication administration record. During interviews, the MDS nurse confirmed responsibility for completing the MDS assessments and acknowledged that the omission of the Anxiety diagnosis was an oversight. The nurse also stated there was no system in place to ensure the accuracy of completed MDS assessments. The DON confirmed the resident's diagnosis of Anxiety and agreed that it should have been included in the MDS. Facility policy and CMS guidelines require that active diagnoses be accurately documented in the MDS, but this was not followed in this instance.