Inaccurate MDS Assessments and Documentation Errors
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for five residents, as identified during a review of clinical records and staff interviews. For one resident, the MDS assessment inaccurately indicated that no as-needed pain medication was administered during the assessment period, despite records showing multiple administrations of morphine for pain. This discrepancy highlights a failure to accurately document the resident's pain management needs. Additionally, three residents who were able to communicate effectively did not have the required Brief Interview for Mental Status (BIMS) and mood interviews completed, as indicated by their MDS assessments. Another resident's discharge status was incorrectly coded as a hospital discharge, while documentation confirmed the resident was discharged home with home health services. These inaccuracies were confirmed through interviews with the Director of Nursing, indicating a pattern of incorrect MDS coding and documentation within the facility.
Plan Of Correction
1. The Minimum Data Set assessment for Resident 7 was modified to reflect the use of the pain medication. A Brief Interview for Mental Status (BIMS) observation was not completed during the look back period for Residents 33, 39 and 49. Thus, modifications of the MDS assessments could not be completed. The Minimum Data Set assessment for Resident 88 was modified to reflect the actual discharge location. 2. The facility's Registered Nurse Assessment Coordinator, or a designee, will audit the opening of the BIMS observation form associated with the assessment reference dates of the next 14 days of quarterly MDS assessments. She will ensure that the designated Interdisciplinary Team staff involved in the BIMS process are provided with the audit information to assure compliance of the observations. 3. The applicable members of the Interdisciplinary Team involved in the assessment process will be re-trained on the Resident Assessment Instrument (RAI) manual coding guidance for Section A discharge location, Section C BIMS and Section J pain management by the Regional Clinical Reimbursement Specialist or a designee. 4. The Regional Clinical Reimbursement Specialist, or a designee, will conduct audits of five random residents' MDS assessments to ensure compliance with the coding of MDS Section A discharge location, Section C BIMS and Section J pain management twice weekly times two, weekly times two and monthly times two. 5. The audit results will be reviewed in the monthly quality assurance meetings to address any identified issues promptly.