Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, resulting in inaccurate assessments. For one resident with a history of chronic obstructive pulmonary disease, a significant change in status MDS was coded to indicate the resident was rarely or never understood. Upon review, the MDS Coordinator acknowledged this was an error and that the resident's cognitive ability had been incorrectly documented. The inaccuracy was not identified until it was brought to the attention of the MDS Coordinator during the survey. For another resident with a history of anxiety disorder and major depressive disorder, the quarterly MDS did not reflect active diagnoses of anxiety or depression, despite these being present in the resident's medical history. The MDS Coordinator confirmed that these diagnoses were omitted from the MDS and subsequently amended the record. Both the DON and Executive Director stated their expectation that the MDS should accurately reflect residents' cognitive status and active diagnoses, but these were not captured at the time of the assessments.