Inaccurate MDS Coding for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents who had physician orders for oxygen therapy. One resident, admitted with diagnoses including chronic systolic heart failure, acute pulmonary edema, dyspnea, and dependence on supplemental oxygen, had a physician order for oxygen as needed for shortness of breath, but the quarterly MDS assessment did not document oxygen therapy under Section O. Similarly, another resident with diagnoses such as chronic obstructive pulmonary disease, pneumonia, heart failure, and emphysema also had a physician order for oxygen as needed, yet their quarterly MDS assessment lacked documentation of oxygen therapy. Interviews with the Director of Nursing and the MDS Coordinator confirmed that both residents had oxygen orders and that the MDS assessments were not accurate, with the MDS Coordinator noting the absence of a relevant policy.