Inaccurate MDS Assessments for Oxygen, CPAP, and Hospice Care
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the care and services provided to two residents. For one resident with diagnoses including COPD and PTSD, clinical records showed the use of intermittent oxygen therapy and CPAP during the assessment period. However, the resident's quarterly MDS did not indicate that oxygen therapy or non-invasive mechanical ventilator therapy had been provided, despite documentation in the clinical record and confirmation from the Registered Nurse Assessment Coordinator that these treatments were administered. For another resident with diagnoses of high blood pressure, dementia, and bipolar disorder, the MDS indicated that the resident was receiving hospice care. A review of the clinical record, however, did not reveal any orders or documentation supporting that hospice services were provided. The Registered Nurse Assessment Coordinator confirmed that this resident had never received hospice care and that the MDS was marked incorrectly. These findings demonstrate that the facility did not follow its policy or the RAI User's Manual guidelines for accurate MDS coding.