Inaccurate Coding and Incomplete Documentation in Resident Assessments
Penalty
Summary
The facility failed to accurately code and complete comprehensive assessments for several residents, as evidenced by discrepancies between the Minimum Data Set (MDS) documentation and supporting medical records. For one resident, the MDS indicated the use of anticoagulant and antidepressant medications during the observation period, but the medication administration record showed that these medications were not in use during that time. Interviews with MDS coordinators confirmed that these medications should not have been coded on the MDS. Another resident was coded on the MDS as having received anticonvulsant medication during the look-back period, but a review of physician orders and the electronic medication administration record revealed no such medication was prescribed or administered. The MDS coordinator confirmed the error in coding. Additionally, the care area assessment (CAA) summaries for two residents were incomplete or incorrectly documented. For one resident, cognitive impairment and urinary incontinence were identified as issues, but the rationale for not addressing these in the care plan was left blank, and the decision not to address them was not explained. The MDS coordinator acknowledged these areas should have been marked to be addressed and properly documented. For another resident, the CAA for urinary incontinence was marked to be addressed in the care plan, but the section requiring a description of the impact and rationale for the care plan decision was left blank. The MDS coordinator confirmed this documentation was incomplete. These findings demonstrate failures in the accurate coding of assessments and completion of care area assessment summaries for multiple residents.