Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for three residents, as identified through record review, reference to the RAI User's Manual, and staff interviews. For one resident with diagnoses including psychosis, schizotypal disorder, and bipolar disorder, the facility did not code the presence of a serious mental illness in Section A1510 of the MDS, despite documentation supporting the diagnosis. Another resident with a suprapubic catheter had their MDS coded for both an indwelling and an external catheter in Section H0100, contrary to the manual's instructions to code only as an indwelling catheter. Additionally, a resident with a documented diagnosis of Parkinson's Disease and a new medication order for carbidopa-levodopa did not have this active diagnosis reflected in Section I of their quarterly MDS. These inaccuracies were confirmed by administrative and corporate staff during interviews, who acknowledged the failures in proper MDS coding. The deficiencies were identified through review of medical records, physician orders, and provider notes, which demonstrated discrepancies between the residents' documented conditions and the information entered into the MDS assessments.