Inaccurate Coding of Falls in MDS Assessments
Summary
The facility failed to accurately code Section J regarding falls for two residents during their Minimum Data Set (MDS) assessments. Resident 14, who has a medical diagnosis of dementia, had an Annual MDS Assessment indicating one fall without injury, but a nursing progress note revealed a fall with a bruise to the right elbow. Similarly, Resident 16, also diagnosed with dementia, had an Annual MDS Assessment indicating one fall without injury, but intradisciplinary notes documented a fall resulting in a head laceration requiring staples and another incident of sliding off the bed without injury. These discrepancies were identified during a review of the clinical records and confirmed in an interview with the MDS Nurse.
Penalty
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A resident with severe cognitive impairment and a history of wandering was not accurately assessed in the MDS, as the assessment failed to document wandering behaviors that were noted in progress notes and by staff. Despite the resident's documented exit-seeking and the use of a wander guard, the MDS did not reflect these behaviors, and staff interviews confirmed the inaccuracy.
Facility staff did not accurately complete a quarterly MDS assessment for a resident with paraplegia and other conditions. The MDS contained errors in coding the resident's functional limitations and mobility, despite the resident being dependent for mobility and using a wheelchair. Staff interviews confirmed the inaccuracies, and leadership was made aware of the findings.
A resident's MDS assessment was inaccurately coded by an LPN, indicating a persistent vegetative state when clinical records showed otherwise. This error resulted in the omission of required responses in cognition, mood, and behavior sections. The mistake was acknowledged by the staff member responsible, and facility leadership was notified.
Facility staff failed to complete the cognitive section of the MDS for a resident with multiple complex diagnoses. The required assessment for cognitive patterns, including the BIMS and staff assessment, was not performed during the designated look-back period, resulting in the section being marked as 'not assessed.' This was confirmed by the RN MDS coordinator during staff interview and review of clinical records.
Facility staff failed to accurately complete the MDS for a resident with multiple diagnoses, including a sacral pressure ulcer that was present and being treated upon admission. The MDS did not reflect the presence of the pressure ulcer, despite clinical documentation and ongoing wound care, due to an oversight by the RN MDS coordinator.
Staff failed to ensure accurate MDS assessments for a resident, documenting lower extremity functional impairment inconsistently with other records and without supporting documentation. The resident, who had severe cognitive impairment, was assessed as having lower extremity limitations on two MDS assessments, despite other assessments indicating no such impairment.
Inaccurate MDS Assessment for Resident Wandering Behavior
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for one resident who was reviewed for accidents. The MDS, which is used to assess behavioral symptoms such as wandering, did not accurately reflect the resident's behaviors during the required 7-day look-back period. Specifically, the MDS indicated that the resident did not exhibit wandering behaviors, despite documentation and staff interviews confirming that the resident had a history of exit-seeking behavior, had wandered to other units, and required a wander guard for safety. The resident had severe cognitive impairment, dementia, and other medical conditions that placed them at risk for elopement, as noted in the care plan and progress notes. Staff interviews, including those with the LPN who documented the wandering and the MDS Coordinator, confirmed that the MDS assessment was not completed accurately and should have indicated the presence of wandering. The Staff Development Coordinator/Infection Preventionist, who was acting as the Director of Nursing, and the Administrator both acknowledged that the MDS was inaccurate and that staff were expected to follow the RAI manual. The deficiency was identified through interviews, record review, and document review, which demonstrated a failure to accurately assess and document the resident's wandering behavior as required.
Inaccurate MDS Assessment for Resident with Mobility Impairments
Penalty
Summary
Facility staff failed to complete an accurate quarterly Minimum Data Set (MDS) assessment for one resident. The resident, who had diagnoses including paraplegia, atherosclerotic cardiovascular disease, and neuromuscular dysfunction of the bladder, was coded in the most recent MDS as having no cognitive impairment and being dependent for bed mobility, transfer, hygiene, and required supervision for eating. However, the MDS also indicated no impairment in lower extremity range of motion and that walking 10 feet was not attempted due to medical or safety concerns. The resident's care plan identified risks for falls related to muscle weakness, poor balance, and psychoactive medications, with interventions such as ensuring the resident wore shoes when ambulating and keeping items within reach. During staff interviews, an LPN recalled that the resident could not walk and used a wheelchair, and the MDS coordinator acknowledged errors in the MDS coding for functional limitations and mobility. The MDS coordinator stated that the RAI manual is the standard used for completing the MDS. The director of nursing, administrator, and assistant director of nursing were informed of these findings. The deficiency was identified through review of facility documents, clinical records, and staff interviews.
Inaccurate MDS Assessment Due to Miscoding of Resident's Level of Consciousness
Penalty
Summary
Facility staff failed to complete an accurate Minimum Data Set (MDS) assessment for one resident. Specifically, the resident's quarterly MDS was incorrectly coded to indicate a persistent vegetative state with no discernable consciousness, despite clinical records and progress notes showing that the resident was never in such a state during their stay. This miscoding in Section B of the MDS led to the omission of responses in subsequent sections related to cognition, mood, and behaviors. The error was made by the LPN serving as the MDS coordinator, who acknowledged the mistake during an interview and confirmed that the resident was never in a persistent vegetative state. The coding instructions from the RAI manual were not followed, as there was no documented diagnosis of coma or persistent vegetative state during the required look-back period. The deficiency was identified through staff interviews and clinical record review, and facility leadership was informed of the findings.
Incomplete MDS Cognitive Assessment
Penalty
Summary
Facility staff failed to provide a complete and accurate Minimum Data Set (MDS) assessment for one resident. The resident was admitted with multiple diagnoses, including metabolic encephalopathy, dysphagia, anemia, protein-calorie malnutrition, asthma, cognitive communication deficit, hypothyroidism, myocardial infarction, and hypertension. The MDS assessment dated [DATE] indicated that the section for cognitive patterns (Section C), which includes the Brief Interview for Mental Status (BIMS) and staff assessment of mental status, was not completed. All items in this section were marked as 'not assessed.' During an interview, the RN MDS coordinator confirmed that the cognitive section of the MDS had not been completed because the required assessment was not performed during the designated 7-day look-back period. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual specifies that the cognitive interview should be attempted with all residents during the look-back period, regardless of their ability to make themselves understood. This deficiency was confirmed through staff interview and clinical record review, with no additional information provided by facility leadership before the end of the survey.
Inaccurate MDS Assessment for Pressure Ulcer
Penalty
Summary
Facility staff failed to complete an accurate Minimum Data Set (MDS) assessment for one resident who was admitted with multiple diagnoses, including cerebrovascular accident, hemiplegia, atrial fibrillation, aphasia, cognitive communication deficit, diabetes, dysphagia with gastrostomy, dementia, hypertension, and a pressure ulcer. The resident's clinical record documented the presence of a stage 2 sacral pressure ulcer upon admission, with corresponding physician orders and daily wound care treatments recorded in the treatment administration records. Despite this documentation, the admission MDS completed for the resident did not indicate the presence of any unhealed pressure ulcers or injuries in Section M0210, omitting the sacral pressure ulcer that was present and being treated. During an interview, the RN MDS coordinator acknowledged that the pressure ulcer should have been coded on the MDS as present upon admission and attributed the omission to an oversight. The deficiency was confirmed through staff interview and clinical record review, and was discussed with facility leadership during the survey.
Inaccurate MDS Assessment of Lower Extremity Range of Motion
Penalty
Summary
Facility staff failed to ensure the accuracy of Minimum Data Set (MDS) assessments for one resident, specifically regarding the assessment of lower extremity functional range of motion. The resident's MDS assessments with assessment reference dates of 2/19/25 and 11/19/24 documented impairment in both lower extremities, which was inconsistent with other MDS assessments for the same resident that indicated no functional limitations. The resident was assessed as able to make self understood and to understand others, with a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating severe cognitive impairment. During the survey, the Administrator-in-Training was unable to provide documentation supporting a decline in the resident's lower extremity functional range of motion as recorded in the MDS assessments. The discrepancy in the MDS documentation was identified through observation, staff interviews, and clinical record review, revealing that the assessments did not accurately reflect the resident's actual condition at the time.
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