Inaccurate Coding of MDS Assessments for Multiple Residents
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for three residents during the recertification/complaint survey. For one resident with diagnoses including polyneuropathy, chronic pain, osteoarthritis, and gout, the MDS incorrectly indicated that the resident did not receive regular pain medication, despite documentation showing the use of Diclofenac gel four times daily and Gabapentin twice daily. The MDS also failed to code the use of anticonvulsant medication. These errors were confirmed by the MDS Coordinator upon review. Another resident's admission MDS did not capture a documented refusal of medication and weight, even though behavior notes and a care plan addressed non-compliance with the treatment plan. The MDS Coordinator confirmed this omission and stated that the existence of a care plan was mistakenly considered sufficient. Additionally, a third resident's MDS inaccurately reported the number of injections received and failed to document opioid administration, despite medical records showing multiple injections and opioid use. These inaccuracies were verified through staff interviews and medical record reviews.