Inaccurate Coding of Depression Diagnosis on MDS Assessment
Penalty
No penalty information released
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Summary
The facility failed to accurately code the Quarterly Minimum Data Set (MDS) assessment for one resident with a diagnosis of depression. The resident, who had a medical history including hypertension, diabetes mellitus, depression, and hyperlipidemia, was receiving Sertraline, an antidepressant, as documented in the Medication Administration Record (MAR). Despite this, the MDS assessment did not indicate an active diagnosis of depression in Section I5800. This inaccuracy was confirmed through medical record review and staff interviews, with the DON, MDS Coordinator, and Administrator all acknowledging that the MDS was not coded correctly for the resident's depression diagnosis.