Inaccurate MDS Coding for Oxygen Therapy
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for one resident who was reviewed for respiratory care. Medical record review showed that the resident was readmitted to the facility and had a physician's order for continuous supplemental oxygen at 4 liters per minute, which was administered daily as documented in the resident's monitor records for both November 2024 and February 2025. However, the MDS assessments for the corresponding periods did not reflect the resident's receipt of oxygen therapy during the 14-day look-back periods. During an interview and concurrent record review, the MDS Coordinator confirmed that the MDS assessments were inaccurately coded and did not accurately represent the resident's ongoing oxygen use.