Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for five residents, resulting in multiple discrepancies between documented diagnoses, care plans, and MDS coding. For one resident, the MDS did not reflect the psychiatric diagnoses of generalized anxiety disorder and major depressive disorder, despite these being documented in psychotherapy notes. Another resident with a diagnosis of schizophrenia and a Level II PASRR indicating a serious mental health condition was incorrectly coded on the MDS as not having a serious mental illness, due to the Social Service Director's lack of awareness of the Level II screening. Additionally, a resident receiving hospice care was not identified as such on the MDS, even though hospice certification and care plans were present, and the MDS nurse acknowledged the error after reviewing the documentation. Further, another resident on hospice was not marked as such on the MDS, despite confirmation from staff, care plans, and census records, with the MDS nurse attributing the omission to an error. Lastly, a resident's MDS indicated a diagnosis of bipolar disorder, but there was no supporting documentation or ICD code on the face sheet, and both the LPN and DON confirmed the resident did not have this diagnosis. These inaccuracies in MDS assessments were identified through interviews, record reviews, and staff admissions of errors or lack of awareness.