Incorrect MDS Coding of Non-Invasive Ventilator Use
Penalty
Summary
The facility failed to accurately code the status of a non-invasive mechanical ventilator on the Minimum Data Set (MDS) assessment for one resident. The resident, who had multiple diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, congestive heart failure, asthma, and chronic kidney disease, was admitted to the facility and was cognitively intact. She was dependent on staff for medication administration, toileting, lower body dressing, and required maximum assistance with showers. The MDS assessment incorrectly indicated that the resident required an invasive mechanical ventilator. Medical record review and staff interviews confirmed that the resident was actually using an Average Volume Pressure Support (AVAPS) ventilator, which is a non-invasive device, and was connected to it nightly via a CPAP/BiPAP mask. Observation showed the resident was not connected to the device at the time of the survey. The MDS nurse acknowledged the error, confirming that the resident should have been coded as using a non-invasive mechanical ventilator. Reference materials, including the RAI User's Manual and a government website, supported that AVAPS is a non-invasive ventilation modality and should not be coded as invasive on the MDS.