Inaccurate Coding of MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for four residents in several key areas, including discharge status, PASRR level, fall history, and use of physical restraints. In one case, a resident was discharged to an assisted living facility, but the MDS incorrectly indicated a discharge to a short-term hospital. Another resident with a documented Level II PASRR was not coded as such on the MDS, despite having a diagnosis of schizophrenia and a valid Level II PASRR determination. Additionally, a resident with a history of multiple falls was coded as having no falls since admission, contrary to incident reports and nursing notes. Finally, a resident was coded as using bed rails as a physical restraint, but observations and staff interviews confirmed that no bed rails were present and the facility was restraint-free. These inaccuracies were identified through record reviews, staff interviews, and direct observation. The MDS Coordinator, who had recently started at the facility, acknowledged the errors and attributed them to oversight or lack of accurate information at the time of assessment. The DON and Administrator both confirmed that MDS assessments are expected to be coded accurately to reflect each resident's actual status and history.