Inaccurate MDS Documentation of Psychotropic Medication Administration
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for one resident, specifically regarding the documentation of psychotropic medications administered during the assessment lookback period. The resident in question had diagnoses of anxiety, depression, and insomnia, and was prescribed multiple psychotropic medications, including an antipsychotic (Abilify) and a hypnotic (trazodone). However, the MDS assessment did not record the administration of antipsychotic and hypnotic medications, despite evidence from the electronic medical record, care plan, and physician orders that these medications were given during the lookback period. Interviews with facility staff confirmed that the MDS should have indicated the use of antipsychotic and hypnotic medications, but this was not done. The facility's policy requires accuracy, timeliness, and completeness in all MDS assessments, referencing the RAI manual. The deficiency was identified through observation, record review, and staff interviews, which revealed the omission in the MDS documentation for the resident who was receiving several psychotropic medications as part of their treatment plan.