Inaccurate MDS Coding for Oxygen Use and Discharge Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments were accurately coded for three residents, as required by facility policy and federal regulations. For one resident with chronic obstructive pulmonary disease (COPD) and a physician's order for supplemental oxygen, the MDS did not reflect the use of oxygen therapy, despite documentation in care plans, progress notes, and vital records indicating the resident received oxygen as needed during the assessment period. The MDS Coordinator confirmed the omission, stating that only the physician order and electronic medication administration record were referenced during the assessment, and acknowledged the MDS was coded incorrectly. Another resident, who had diagnoses including speech and language deficits, dysphagia, aphasia, apraxia, dementia, seizures, and heart failure, was discharged to home with home health services. However, the discharge MDS incorrectly indicated the resident was discharged to a hospital setting. The MDS Coordinator admitted to the error, explaining that she had attended the care plan meeting and was aware the resident returned home, but the MDS was not coded accordingly. The Director of Nursing and Administrator both confirmed the importance of accurate MDS coding and attributed the error to human mistake. A third resident with a history of COPD, idiopathic interstitial pneumonia, and dependence on supplemental oxygen was also affected by inaccurate MDS coding. Although the resident's care plan, physician orders, and progress notes documented regular use of supplemental oxygen, the MDS did not indicate oxygen use during the lookback period. The MDS Coordinator and DON both confirmed, after reviewing the records, that the resident was using oxygen intermittently and that the MDS should have reflected this. Interviews with nursing staff further confirmed the resident wore supplemental oxygen continuously at their request.