Inaccurate Coding of RAI-MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately code the Resident Assessment Instrument-Minimum Data Set (RAI-MDS) for two residents, resulting in assessments that did not reflect their current medical status. For one resident, the RAI-MDS assessment did not indicate a diagnosis of schizophrenia, despite the admission record listing schizophrenia among the resident's diagnoses. Both the Assistant Director of Nursing and the MDS Nurse confirmed during interviews that the omission was an oversight and that the assessment should have included the schizophrenia diagnosis, as required by the RAI manual. For another resident, the RAI-MDS assessment failed to document the presence of a stage 1 pressure ulcer that was identified upon admission. The admission assessment and physician's orders confirmed the existence of the pressure ulcer, and the Assistant Director of Nursing acknowledged that the assessment was incorrectly coded. The RAI manual specifies that skin conditions, including pressure ulcers, must be accurately documented to ensure a complete assessment. These failures resulted in the MDS assessments not accurately reflecting the residents' current health conditions.