Inaccurate MDS Coding for Falls, Treatments, and Symptoms
Penalty
Summary
Facility staff failed to ensure the accuracy of Minimum Data Set (MDS) assessments for multiple residents, as evidenced by medical record reviews and staff interviews. In several cases, significant clinical events and treatments were not properly coded in the MDS. For example, one resident experienced an unwitnessed fall resulting in a head laceration requiring staples, but the MDS did not capture the fall with injury. Additionally, the same resident received antifungal powder for a rash, but this treatment was not documented in the relevant MDS section. Another resident with a history of visual hallucinations, including seeing snakes, had these symptoms documented in both progress notes and a physician's history and physical, but the admission MDS failed to capture the presence of hallucinations. In a separate case, a resident who was found on the floor after attempting to walk was not recorded as having had a fall in the MDS, despite clear documentation in the progress notes. A further incident involved a resident with chronic inflammatory demyelinating polyneuritis who was assisted by staff after sliding from a wheelchair. The resident was placed on the floor and then transferred using a Hoyer lift, with the event witnessed by a family member. However, the MDS assessment did not reflect that a fall had occurred. In each instance, the MDS Coordinator confirmed the errors in coding during interviews with surveyors.