Inaccurate MDS Assessments for Oxygen Use, Tobacco Use, and Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the clinical status and care needs of residents. For one resident with chronic obstructive pulmonary disease, diabetes, and chronic respiratory failure who was dependent on supplemental oxygen, the admission MDS did not indicate the use of oxygen therapy in Section O, despite clear documentation in the medical record, physician orders, and direct observation of oxygen use. Additionally, this same resident was identified as a smoker through medical records, physician orders, and direct observation, but Section J of the MDS incorrectly indicated that the resident was not a tobacco user. The MDS Lead acknowledged these inaccuracies and confirmed that the assessment should have captured both oxygen and tobacco use. Another resident was incorrectly coded in the MDS as having an active psychotic disorder other than schizophrenia, even though there was no such diagnosis documented in the medical record. The Director of Nursing confirmed the absence of this diagnosis. The RAI manual specifies that only physician-documented diagnoses with a direct relationship to the resident's current status should be coded as active. These inaccuracies in the MDS assessments were identified through observation, interview, and record review.