Inaccurate MDS Coding for Respiratory Care, Antibiotic Use, and PASRR Status
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for three residents in the areas of respiratory care, antibiotic use, and PASRR status. For one resident with a diagnosis of sleep apnea and a physician order for nightly CPAP use, the MDS assessment did not reflect the use of a CPAP device, despite documentation in the Medication Administration Record (MAR) and confirmation from nursing staff that the device was applied nightly. The MDS nurse responsible for coding acknowledged that the information was missed during the assessment process. Another resident was incorrectly coded as receiving antibiotics on the MDS assessment, even though the MAR showed no antibiotics were administered during the assessment period following the resident's return from the hospital. The MDS coordinator confirmed the error after reviewing the records. Additionally, a third resident with schizoaffective disorder and a PASRR level II determination was not coded appropriately on the admission MDS. The MDS nurse responsible was unfamiliar with the expiration of the PASRR level II and mistakenly coded it as a level I, resulting in inaccurate documentation.