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 four residents during a complaint survey. In one case, a resident received Oxycodone for pain, but the MDS assessment did not capture the use of an opioid. Another resident was administered scheduled pain medications, including Lidocaine patches, Voltaren gel, and Gabapentin for osteoarthritis, but the MDS failed to document the use of scheduled pain medications and anticonvulsants. The MDS Coordinator confirmed these omissions during interviews, attributing them to oversight. Additionally, a resident who was administered Amoxicillin for a urinary tract infection and received Zinc Oxide cream for skin treatment was not accurately coded for antibiotic use or topical medication application on the MDS. Another resident with a history of falls experienced a fall during their stay, but both the quarterly and discharge MDS assessments failed to document this event. The MDS Coordinator acknowledged these errors, confirming that the assessments did not accurately reflect the residents' conditions and treatments.