Inaccurate MDS Coding for Hospice and BiPAP Therapy
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for two residents. For one resident under hospice care since March, the quarterly MDS assessment incorrectly indicated that the resident was not receiving hospice care, despite medical records and staff interviews confirming ongoing hospice services. The error was identified during a review of the MDS assessment and confirmed by the MDS nurse coordinator, who acknowledged the resident should have been coded as receiving hospice care. In a separate case, another resident with chronic respiratory failure, CHF, and COPD had an active order and care plan for BiPAP therapy. However, the annual MDS assessment did not reflect the use of BiPAP therapy, despite documentation and physician orders supporting its use. The MDS nurse coordinator confirmed responsibility for completing the relevant MDS section and acknowledged the omission, verifying that the assessment was inaccurately coded.