Inaccurate MDS Coding for Resident Assessments
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, as evidenced by discrepancies between medical records and MDS documentation. For several residents, significant clinical events and treatments were not properly recorded in the MDS. One resident experienced a substantial weight loss and a fall, neither of which were accurately reflected in the corresponding MDS sections. Additionally, the administration of hypoglycemic medications and insulin was omitted from the MDS, while an opioid was incorrectly documented as administered when it was not present in the medication administration record. Another resident was admitted with bilateral heel wounds and received ongoing wound care and antibiotics, but the MDS failed to capture the presence of pressure ulcers, venous ulcers, and related treatments. The same resident's MDS also did not reflect the administration of multiple medications, including insulin, diuretics, opioids, antidepressants, antibiotics, and anticoagulants, despite clear documentation in the medical and treatment records. Similar omissions were found for other residents, where falls, pressure ulcers, and the use of specific medications such as antibiotics and anticoagulants were not accurately coded in the MDS, even though these events and treatments were documented elsewhere in the medical record. In one case, a resident's MDS assessment incorrectly indicated the presence of a pressure ulcer that had already healed, and failed to document the use of antiplatelet, hypoglycemic, and antipsychotic medications that were administered during the assessment period. Interviews with MDS coordinators confirmed the presence of these errors across multiple assessments, indicating a pattern of inaccurate MDS coding that did not align with the residents' actual clinical status and care provided.