Inaccurate MDS Coding for Falls, Antipsychotic Use, and GDR Documentation
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for four residents in the areas of falls, gradual dose reduction (GDR), and diagnoses. For one resident with a history of falls and a recent fall incident, the MDS was not updated to reflect the fall, despite documentation in the progress notes and care plan. The MDS Coordinator acknowledged that the assessment should have been coded for falls, and the DON confirmed the expectation for accurate and timely MDS completion. Another resident, who was receiving antipsychotic medication for paranoid schizophrenia, was incorrectly coded on the MDS as not receiving an antipsychotic. The MDS Nurse admitted to missing the correct coding for antipsychotic use and GDR questions, citing being the sole MDS nurse for an extended period. The DON and Administrator both stated that the MDS should have been coded accurately and that the interdisciplinary team should have reviewed the assessment. Two additional residents receiving antipsychotic medications were coded on their MDS assessments as not having a GDR attempted and without documentation of a GDR being clinically contraindicated, despite psychiatric notes indicating that a GDR was contraindicated. The MDS Nurse did not identify the documentation in the medical record, and both the DON and Administrator indicated that the MDS should have reflected the clinical contraindication for GDR. All errors were attributed to incomplete review of the medical records and lack of interdisciplinary review prior to MDS submission.