Failure to Accurately Code Depression and Care Plan for Psychotropic Use on MDS
Penalty
Summary
Surveyors identified that the facility failed to ensure an accurate MDS assessment and related care planning for a resident with a documented diagnosis of depression. The resident was admitted with Parkinson’s disease, muscle weakness, and difficulty walking, and had an active order for Mirtazapine 15 mg for depression manifested by overconcern with health issues. The resident’s MDS indicated they felt little interest or pleasure in doing things and felt down, depressed, or hopeless half or more of the days, but depression was not coded as an active diagnosis on the MDS. During interview and record review, an LVN confirmed there was no care plan addressing depression and that the diagnosis of depression was not triggered on the MDS, despite the resident receiving a medication ordered for depression. Further review with the DON and MDS nurse showed that the resident had received a depression diagnosis from the hospital and that a psychiatrist at the GACH had continued the Mirtazapine upon readmission. The MDS nurse stated that once the order was entered into the electronic chart, there was no alert to trigger the depression diagnosis in the MDS. Review of the IDT care conference documentation showed no recorded review of medications, and the DON and MDS nurse confirmed there was no care plan documented for depression or for the use of Mirtazapine. The DON and MDS nurse stated that without a care plan, something could be missed, and that the care plan is the comprehensive plan of care for the resident. The facility’s psychotropic medication use policy required that residents not receive psychotropic medications without a clinically indicated, documented condition and that the IDT evaluate and document the resident’s underlying condition and medications on admission or readmission, which was not reflected in the records reviewed for this resident.
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