Inaccurate MDS Coding for Respiratory Care and Psychiatric Diagnosis
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents in the areas of respiratory care and active diagnosis. One resident, admitted with pneumonia, had a physician's order for continuous oxygen therapy and received oxygen daily as documented in the Medication Administration Record. However, the resident's quarterly MDS assessment did not reflect the use of oxygen therapy in the Special Treatments and Programs section. This omission was acknowledged by the MDS nurse as an oversight. Another resident, admitted with an anxiety disorder and an active diagnosis of bipolar disorder, was receiving daily antipsychotic medication for bipolar disorder as documented in the Medication Administration Record. Despite this, the quarterly MDS assessment did not indicate an active diagnosis of bipolar disorder in the Psychiatric/Mood Disorder section. This was also acknowledged by the MDS nurse as an oversight. The Director of Nursing and the Administrator both stated that they expected MDS assessments to be coded accurately.