Failure to Accurately Code Schizophrenia Diagnosis in MDS
Summary
The facility failed to accurately code a resident's diagnosis of schizophrenia in the Minimum Data Set (MDS), despite the diagnosis being documented in the resident's medical record. The resident was admitted and readmitted with multiple diagnoses, including schizophrenia, as indicated in the History and Physical (H&P) dated after the most recent admission. However, review of the MDS showed that the checkbox for schizophrenia under the psychiatric/mood disorders section was not marked, resulting in the resident's MDS not reflecting the current diagnosis. Interviews with the MDS Coordinator confirmed that the diagnosis of schizophrenia was present in the medical record and should have been coded on the MDS to accurately represent the resident's condition. The Director of Nursing also acknowledged the importance of accurate coding for care planning and treatment. The omission was identified through record review and staff interviews, and it was noted that failure to code an active diagnosis can result in inaccurate assessments and improper care planning, as referenced in the CMS RAI User's Manual.
Plan Of Correction
F-tag: 640 Encoding/Transmitting Resident Assessments Immediate corrective actions: On 4/29/2025, MDS Coordinator conducted a meeting with the IDT team and psychiatrist to clarify Resident 15's diagnosis of Schizophrenia. On 4/29/2025, MDS Coordinator modified Resident 15's MDS to reflect current diagnosis of Schizophrenia. On 5/2/2025 & 5/23/2025, DON & MDS Consultant provided in-service/training and re-education to MDS/Designee with emphasis on accuracy of encoding/transmission of assessment. Identification of others at risk: On 05/02/2025, the MDS reviewed clinical records of active residents with diagnosis of Schizophrenia. No other residents were identified with the same deficient practice. Process to prevent recurrence: On 05/02/25 and 05/20/25, the DON provided inservices/retraining to MDS staff (LVN, RN) to reinforce policy on accuracy of coding in MDS and transmission assessment. Monitoring process: The MDS consultant will review MDS of 5 residents with current diagnosis of Schizophrenia x 3 months to ensure accuracy of coding in the MDS. DON will report MDS findings to the QAPI committee monthly for further recommendations, resolution, and follow-up. Completion date: 5/23/2025 NotSpecified
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident’s discharge MDS was not encoded and transmitted to the State within the required timeframe. The transfer form showed the resident was discharged, but the MDS record did not include a discharge assessment for that discharge, and the Regional MDS Coordinator said the facility MDS representative missed it and the facility follows RAI without a policy.
Failure to complete a reentry assessment for a resident who returned to the facility after a discharge with return anticipated. The record showed the resident came back to the facility, but there was no evidence that the required assessment was completed, and an E3 confirmed this during interview.
Failure to complete and submit a discharge MDS for a resident. Staff acknowledged the discharge assessment was never initiated or completed after the resident discharged, despite it being their responsibility and required for timely CMS submission. The resident had CKD stage 4, severe, and a BIMS score of 11 indicating moderate cognitive impairment.
Late Submission of Discharge MDS: The facility failed to timely transmit a resident’s Discharge Return Not Anticipated MDS to CMS after the resident was discharged home. The resident had multiple chronic conditions, including dementia, CKD, DM2, HTN, depression, psychosis, and metabolic encephalopathy, and was documented with severe cognitive impairment. The MDS was completed by the MDSC but not submitted until months later, despite the MDSC and DON acknowledging it should have been submitted within the required timeframe.
The facility failed to submit discharge MDS assessments for two residents who were discharged from the LTC facility. One resident had anemia, HTN, and atherosclerotic heart disease, and another had DM, cirrhosis of the liver, and HTN. The DON confirmed the assessments were not submitted to CMS, and the RAI manual requires discharge assessments to be completed and submitted within the required timeframes.
Failure to timely complete and transmit MDS assessments: completed assessments for two residents were still marked export ready and had not been sent to CMS, while another resident’s admission and Medicare 5-day MDSs remained in progress. The MDS Coordinator said the facility was behind, corporate staff were supposed to ensure exports, and the DON acknowledged the assessments should have been completed.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to encode and transmit the resident discharge assessment to the State within 7 days of assessment for one resident, Resident #9. Review of the EXCEL-SNF to Hospital Transfer form showed the resident was discharged on 7/15/2026, but review of the resident’s MDS assessments did not show a Discharge MDS Assessment for that discharge date. During interview, the Regional MDS Coordinator stated that the resident’s MDS was not updated because the facility MDS representative just missed it and that the facility does not have a policy, relying instead on the RAI.
Failure to Complete Reentry Assessment
Penalty
Summary
The facility failed to encode a subset of assessment items after a resident's reentry to the facility for 1 of 12 residents reviewed. Resident 34's discharge MDS dated May 27, 2024, indicated the resident was discharged with return anticipated. A late entry progress note dated June 7, 2026, documented that the resident returned to the facility on June 6, 2026. Review of the clinical record found no evidence that a reentry assessment was completed, and Employee E3 confirmed during interview on July 30, 2026, at 11:52 a.m. that the reentry assessment had not been completed.
Failure to Complete and Submit Discharge MDS
Penalty
Summary
The facility failed to complete the discharge MDS for Resident #104 in accordance with CMS guidelines. Record review and staff interviews showed that the discharge assessment was never initiated or completed after the resident discharged, even though MDS Nurse #2 stated it was her responsibility to complete it and acknowledged it should have been initiated the day after discharge and submitted to CMS within the required timeframe. The facility policy stated it follows the RAI process per CMS protocol. Resident #104 was admitted with diagnoses including Chronic Kidney Disease, Stage 4, Severe, and an MDS review showed a BIMS score of 11, indicating moderate cognitive impairment.
Late Submission of Discharge MDS
Penalty
Summary
The facility failed to ensure the MDS for Resident 109 was transmitted to CMS within the required timeframe after the resident was discharged home on 2/9/2026. Resident 109 was admitted on 9/12/2025 with diagnoses including metabolic encephalopathy, type 2 diabetes, hypertension, dementia, chronic kidney disease, depression, and psychosis. The Discharge Return Not Anticipated MDS indicated the resident had severe cognitive impairment and was discharged home from the facility. During interview and record review, the MDS Coordinator stated the Discharge Return Not Anticipated MDS was completed on 2/13/2026 but was not submitted to CMS until 7/23/2026. The MDS Coordinator stated the assessment should have been submitted earlier, within 14 days after the discharge, and the DON also stated the submission was too late and should have been completed within 14 days of the completion date. The facility policy stated resident assessments are to be conducted and submitted in accordance with current federal and state submission timeframes, and the RAI Manual requires the discharge assessment to be completed within 14 days after discharge and submitted within 14 days after the MDS completion date.
Late Submission of Discharge MDS Assessments
Penalty
Summary
The facility failed to submit completed discharge MDS assessments within the required timeframe for two residents who were discharged from the facility. Resident #2 was admitted with diagnoses including anemia, hypertension, and atherosclerotic heart disease and was discharged without a discharge MDS assessment in the medical record. Resident #3 was admitted with diagnoses including diabetes mellitus, cirrhosis of the liver, and hypertension and was also discharged without a discharge MDS assessment in the medical record. During interview, the DON confirmed the facility had not submitted the discharge assessments for both residents to CMS. Review of the facility policy stated assessments were to be completed and submitted according to current federal and state timeframes, and the RAI manual stated discharge assessments must be completed within 14 days of discharge and submitted within 14 days of the MDS completion date.
Failure to Timely Complete and Transmit MDS Assessments
Penalty
Summary
The facility failed to electronically transmit encoded, accurate, and complete MDS data to CMS within 14 days after completion of resident assessments for 3 of 3 sampled residents. R4’s MDS assessment for discharge/return anticipated dated 07/01/26 had been completed but was still listed as export ready and had not been exported to CMS. R1’s MDS assessment for discharge/return not anticipated dated 06/19/26 had also been completed but not exported and was listed as export ready. R5’s MDS assessments for Medicare/5-day and admission, both dated 07/06/26, were listed as in progress on 07/21/26. During interview, the MDS Coordinator stated the facility was behind, that corporate staff were supposed to ensure the assessments were exported, and that the coordinator was still training and had not been taught how to do everything. The MDS Coordinator acknowledged the assessments for R4, R5, and R1 were not complete and should have been. The DON also acknowledged the assessments should have been completed.
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