Inaccurate Coding of Resident Assessments
Penalty
Summary
The facility failed to ensure that resident assessments were accurately coded to reflect the current status of three residents. For one resident with dementia, heart failure, and COPD, a new open wound was documented in a progress note, but the corresponding quarterly MDS assessment did not indicate the presence of any wounds. Staff interviews confirmed that the wound should have been captured in the assessment. Another resident with severe intellectual disabilities and a history of metabolic acidemia had their feeding tube removed and was not on tube feeding as of a specific date, yet the quarterly assessment inaccurately documented the presence of a PEG tube. Staff confirmed the resident was no longer on tube feeding at the time of the assessment. A third resident with dementia and mobility issues experienced two documented falls within a month, as shown in incident reports. However, the quarterly assessment for this resident indicated no falls had occurred since admission or the previous assessment. Staff interviews acknowledged that the assessment should have included both falls. These discrepancies between clinical documentation and MDS assessments demonstrate a failure to ensure accurate resident assessments.