Inaccurate MDS Assessment Coding for Multiple Residents
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. In several cases, injections, falls, fractures, pain management, medication administration, and hospice care were not properly recorded in the MDS, despite being documented elsewhere in the residents' medical records. For example, one resident received a prescribed injection for diabetes, but the MDS assessment indicated no injections were given during the relevant period. Another resident experienced an unwitnessed fall resulting in a fracture, but the MDS failed to document both the fall and the injury. Additional errors included the omission of falls and related injuries for other residents, as well as the failure to record the administration of anti-convulsant and opioid medications. In one instance, a resident was on hospice care, but this was not captured in the MDS assessments. Pain management was also inaccurately documented, with residents receiving scheduled or PRN pain medications that were not reflected in the MDS coding. These inaccuracies were confirmed through interviews with the MDS Coordinator, who acknowledged the errors in assessment coding. The deficiencies were identified during a complaint survey, with six residents specifically noted as having inaccurate MDS assessments. The errors spanned various sections of the MDS, including medication administration, falls, fractures, pain management, and hospice care, indicating a pattern of incomplete or incorrect documentation that did not align with the residents' actual care and medical records.