Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents, leading to discrepancies in their Minimum Data Set (MDS) documentation. For one resident with diagnoses including congestive heart failure and chronic kidney disease, the MDS inaccurately indicated the receipt of an anticoagulant, despite the clinical record showing no prescription or administration of such medication during the assessment reference date (ARD). This error was identified through a review of the resident's clinical records and confirmed by the Director of Nursing (DON). Another resident, diagnosed with bipolar disorder and dementia, had discrepancies in the documentation of their antipsychotic medication management. The MDS inaccurately recorded the dates when a gradual dose reduction was deemed clinically contraindicated, conflicting with the psychiatric visit notes. These errors were confirmed during a staff interview with the Nursing Home Administrator and the DON, who acknowledged the coding inaccuracies in the MDS assessments.
Plan Of Correction
1. MDS correction was completed and submitted for resident 8 to indicate that he did not receive an anticoagulant. MDS correction was completed and submitted for Resident 36 to reflect the most recent date of GDR contraindication. 2. A comprehensive review of current residents will be done to ensure correct coding of anticoagulant use. A comprehensive review of current residents taking an antipsychotic medication will be completed to ensure that the MDS is coded correctly in regards to Gradual Dose Reductions. 3. The facility will take further steps to validate the problem does not reoccur by re-educating the Clinical Reimbursement Coordinators on FTAG 641 accuracy of assessments with focus on anticoagulation therapy and Gradual Dose Reduction coding. 4. Compliance will be monitored by the Director of Nursing/Designee using the MDS Coding Audit through three MDS Assessment audits weekly x 3 weeks to validate that the MDS is coded accurately in regards to anticoagulant use and Gradual dose reductions. Results will be reported to the QAA committee and the QAA committee will determine the need for further audits.