Failure to Accurately Code Mood and Behavior in MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents regarding their mood and behavioral conditions. For one male resident with chronic respiratory failure, anxiety, and a history of refusing care and medications, the quarterly MDS assessment did not document any mood or behavioral issues, despite care plans and progress notes indicating frequent anxiety, refusal of care, false accusations, and attention-seeking behaviors. The resident's care plan specifically addressed behavioral problems and interventions, and physician notes documented ongoing behavioral concerns, yet these were not reflected in the MDS. A female resident with diagnoses including unspecified dementia, mood disorder, schizoaffective disorder, and major depressive disorder also had an MDS assessment that failed to document any mood or behavioral symptoms. Her care plan and physician orders indicated significant mental health issues, including risk for self-harm, aggression, and labile mood, with interventions in place to address these concerns. Observations and interviews with staff and family confirmed ongoing behavioral and mood disturbances, but these were not captured in the MDS assessment. Interviews with facility staff, including the MDS Coordinator, ADON, and DON, confirmed that the MDS assessments for both residents did not accurately reflect their mood and behavioral status. Staff acknowledged that these omissions could lead to inaccurate care planning and that the MDS Coordinator was responsible for ensuring assessment accuracy. The deficiency was identified through record reviews, staff interviews, and direct observation, revealing a failure to document and code mood and behavioral issues in the MDS for residents with clear histories and ongoing symptoms.