Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for four residents, resulting in incorrect coding of key clinical information. For one resident with Alzheimer's disease, the admission source was inaccurately coded as a nursing home, despite documentation and staff interviews confirming the resident was admitted from a private home after living with a family member. Another resident with dementia and COPD had daily use of limb restraints in a Broda chair, as ordered by a physician, but the MDS assessment did not reflect this use during the required look-back period. A third resident with COPD, dementia, and schizophrenia was incorrectly coded as receiving anticoagulant medication on the MDS, even though the medication had been discontinued prior to the assessment period. Additionally, a resident with Alzheimer's and Parkinson's disease was coded as not having a life expectancy of less than six months, despite being admitted to hospice care, which was documented in the medical record. Interviews with staff confirmed these inaccuracies and revealed a lack of facility policy on MDS coding, with reliance on the RAI manual for guidance.