Inaccurate MDS Assessments for a Resident
Penalty
Summary
The facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for a resident. The resident was readmitted from a hospital stay with a diagnosis of aspiration pneumonia and sepsis. However, subsequent MDS assessments inaccurately documented the resident as having pneumonia, septicemia, and a multidrug-resistant organism (MDRO) without any supporting evidence in the clinical record. These errors persisted across multiple assessments conducted on May 30, August 1, August 30, and November 27, 2024. An interview with the Administrator confirmed that these assessments were coded in error, as there was no documented evidence of the resident having these conditions since December 2023.
Plan Of Correction
1. The facility immediately corrected Resident 1's MDS and a modification of the MDS's was completed to reflect accurate diagnoses and care needs, removing coding that was selected for resident for having an active diagnosis of an infection which included one of the following: pneumonia, septicemia (a bloodstream infection), and a multidrug resistant organism (MDRO, an infection susceptible to certain antibiotics). There was no documented evidence in Resident 1's clinical record to indicate that she had a current pneumonia infection, septicemia, or an MDRO. MDS's were modified and diagnoses were updated to reflect current active diagnoses. 2. MDS staff member conducted a 30 day look back reviewing any residents who were coded for having a current pneumonia infection, septicemia, or an MDRO to ensure coding was accurate. - Active diagnoses were verified with progress notes, physician orders, and laboratory results with the MDS submission. - Any discrepancies will be addressed and modified/updated to reflect current care needs during the look back. 3. NHA to educate MDS staff providing re-education on: - Proper MDS coding practices, including reviewing physician orders and clinical documentation before finalizing assessments. - The importance of accurate coding to ensure appropriate care planning and reimbursement. 4. The MDS Coordinator or designee will audit 5 random selected MDS assessments per month for three months to verify if coding current pneumonia infection, septicemia, or an MDRO to ensure coding was accurate. Audit will include Active diagnoses accurately reflect the resident's current clinical condition during the MDS assessment look back. Audits will be reviewed in QAPI.