Inaccurate MDS Assessment of Resident's Behavioral Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the behavioral status of a resident with diagnoses including Alzheimer's disease, psychosis, and depression. Despite documented evidence in the resident's records, such as the Medication Administration Record and Order Summary Report, indicating multiple episodes of hallucinations and the use of antipsychotic medication for psychosis manifested by auditory and visual hallucinations, the MDS assessment did not indicate the presence of hallucinations. Additionally, a Change In Condition Evaluation documented an incident involving the resident in a physical altercation, with behavioral symptoms noted. During an interview and record review, the Health Information Manager acknowledged that the MDS assessment was inaccurate and that the section for hallucinations should have been marked. The facility's policy requires that each person completing a section of the MDS attests to its accuracy, referencing the Resident Assessment Instrument User's Manual as guidance. The failure to accurately document the resident's behavioral symptoms on the MDS constitutes a deficiency in the assessment process.