Inaccurate MDS Coding for Medications, Pressure Ulcers, and PASRR Status
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for multiple residents in several key areas, including medications, pressure ulcers, and Preadmission Screening and Resident Review (PASRR) status. For several residents, the MDS assessments indicated the administration of medications such as anticoagulants, insulin, and hypoglycemics, despite medication administration records (MARs) showing no physician orders or evidence that these medications were given during the assessment periods. The MDS Coordinator confirmed these discrepancies during interviews, acknowledging that the assessments were coded incorrectly. In addition, the facility did not accurately document the presence and status of pressure ulcers for certain residents. For example, one resident's admission MDS assessment failed to reflect the presence of pressure ulcers that were documented in nursing notes, while another resident's quarterly MDS assessment did not indicate that a pressure ulcer was present on admission, despite wound care documentation to the contrary. The MDS Coordinator attributed these errors to oversight and lack of clarification regarding wound staging and documentation. The facility also failed to correctly code PASRR Level II status for a resident with a serious mental illness, as the MDS assessment did not reflect the resident's active Level II PASRR determination. The Social Worker described a process of regularly auditing PASRR status and communicating updates to the MDS Coordinator, but the error was still not caught prior to the assessment. Throughout the report, the Administrator and Director of Nursing stated their expectation that MDS assessments be completed accurately.