Inaccurate MDS Coding for Resident Assessment and ADL Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, resulting in deficiencies related to resident assessment accuracy. For one resident with diagnoses including schizophrenia, encephalopathy, and morbid obesity, the clinical record showed a Level II PASRR outcome document was on file. The admission MDS assessment correctly indicated a positive Level II PASRR, but the subsequent annual MDS assessment was incorrectly coded as negative for Level II PASRR, despite no change in the resident's status. The Director of Social Work confirmed the inconsistency and was unable to explain the miscoding. For another resident with a history of malignant neoplasm of the left breast, moderate protein calorie malnutrition, and dysphagia, the annual MDS assessment indicated the resident was independent with eating. However, the care plan, nurse aide documentation, and direct observations showed the resident required extensive or total assistance with eating, including the use of adaptive equipment and staff feeding. The Director of Nursing Services acknowledged the conflicting documentation and could not explain the incorrect MDS coding. These findings were based on observations, record reviews, and staff interviews.