Inaccurate MDS Assessment for Resident with PASRR Level II Outcome
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for one resident who was reviewed for MDS assessments. According to the MDS 3.0 Resident Assessment Instrument (RAI) Manual and the facility's own policy, assessments must accurately reflect a resident's status, including the identification of serious mental illness as determined by a Level II Pre-admission Screening and Resident Review (PASRR). Medical record review showed that a resident admitted with diagnoses of Bipolar Disorder and Major Depressive Disorder had a PASRR Level II outcome indicating a serious mental illness. However, the significant change MDS assessment did not code for the PASRR Level II condition, despite the resident having active diagnoses of Bipolar Disorder and Depression. Further review of the resident's records, including a psychiatric nurse practitioner's note, confirmed ongoing treatment for bipolar disorder and depression. During interviews, the RN MDS Coordinator acknowledged that the MDS assessment was inaccurate and did not reflect the PASRR Level II outcome. The DON also confirmed that the facility did not ensure the accuracy of the significant change MDS assessment for this resident, as required by facility policy and regulatory guidelines.