Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
Facility staff failed to accurately code the Minimum Data Set (MDS) assessments for three residents. For one resident, the MDS indicated the use of high-risk anticoagulant medications, but a review of the physician order sheet showed no such medications were ordered. Another resident, diagnosed with chronic kidney disease and dependent on renal dialysis, was not marked as receiving dialysis on the MDS, despite care plan documentation and staff interviews confirming regular dialysis treatments. A third resident, who was out on pass in the care of a family member, was incorrectly coded on the MDS as having been hospitalized, contrary to progress notes documenting the actual situation. These inaccuracies were identified through record review and staff interviews, revealing errors in the completion of MDS assessments for all three residents reviewed in this sample.