Inaccurate MDS Coding for Mental Illness and Medication Use
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents, resulting in deficiencies related to the proper coding of mental illness and medication usage. For one resident with diagnoses including schizophrenia, dementia, and type II diabetes, the MDS assessment did not accurately reflect the presence of a mental illness as required by Section A1500. Despite documentation from the state designated authority confirming a Level II PASARR and the presence of a mental illness, the MDS was incorrectly coded to indicate the absence of such conditions. This error was confirmed by both the Business Office Manager and the MDS Coordinator in-training, who acknowledged that the coding did not align with the resident's documented status. For another resident with diagnoses including brain cancer, bipolar disorder, and mood disorder, the MDS assessments inaccurately reported the use of certain medication classes. The resident's records showed that antianxiety, anticoagulant, and opioid medications had been discontinued prior to the assessment periods, and only an antidepressant was currently prescribed. However, the MDSs continued to indicate the use of antianxiety, anticoagulant, and opioid medications, while failing to document the use of an antidepressant. This discrepancy was identified through a review of the resident's medication administration records, physician orders, and care plan. Interviews with staff revealed that MDS assessments were being completed by an outside coordinator due to ongoing staff training, and that the RAI Manual was available but not always referenced. Both the off-site and in-training MDS Coordinators acknowledged errors in the completion of the MDS, attributing them to oversight and reliance on experience rather than strict adherence to the RAI Manual. The facility's instructions for completing Section N of the MDS were outdated, and staff confirmed that mistakes had been made in coding, particularly regarding the accurate reflection of PASARR status and medication use.