Inaccurate MDS Assessments for Diagnoses and Medication Use
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately recorded for two residents. For one resident, the medical record showed an attending provider's order for an antipsychotic medication with a diagnosis of dementia with behavioral disturbance. However, the MDS assessments documented the diagnosis as dementia without behavioral disturbance, which did not reflect the updated diagnosis in the resident's record. This discrepancy was confirmed by the MDS Coordinator, who acknowledged missing the update in the resident's diagnosis. For another resident, MDS assessments documented a diagnosis of psychotic disorder, but there was no supporting documentation in the medical record. Specifically, there was no evidence of treatment for psychotic disorder in the seven days prior to the assessment, nor was there an attending provider's note documenting the diagnosis in the previous sixty days. The MDS Coordinator confirmed that these MDS assessments were recorded inaccurately.