Inaccurate MDS Assessments for Dialysis, Medication, and Hospice Coding
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for four residents, resulting in multiple instances of incorrect coding. For one resident, the admission MDS assessment inaccurately documented that the resident was receiving dialysis services, despite no evidence in the physician orders, progress notes, or resident interview to support this. Two other residents had MDS assessments that incorrectly indicated the administration of antipsychotic medications during the look-back period, although medication and treatment administration records did not show any such medications were given. In both cases, MDS coordinators acknowledged the discrepancies during side-by-side record reviews. Additionally, another resident's quarterly MDS assessment failed to indicate that hospice services were being provided, even though physician orders and progress notes confirmed hospice care had been initiated and was ongoing. The MDS coordinators also acknowledged this error during a review. These inaccuracies were identified through record reviews and staff interviews, with documentation and resident statements directly contradicting the information recorded in the MDS assessments.