Inaccurate MDS Coding for Oxygen Use
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment was coded accurately regarding oxygen use. The resident, who had multiple complex diagnoses including metabolic encephalopathy, pneumonitis, cerebrovascular accident with right-sided hemiplegia, epilepsy, diabetes, dysphagia, anemia, hypoxemia, sepsis, severe malnutrition, hypertension, and acute respiratory failure with hypoxia, was admitted and readmitted with ongoing medical needs. Physician orders and the Treatment Administration Record (TAR) documented continuous oxygen use at two liters per nasal cannula, and direct observation confirmed the resident was receiving oxygen. However, the quarterly MDS assessment did not indicate the resident's use of oxygen, and there was no care plan addressing oxygen use. This discrepancy was confirmed by a registered nurse during an interview.