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 multiple residents, as evidenced by discrepancies between the MDS documentation and the residents' medical records. In several cases, the MDS did not reflect significant clinical events or medication administration, such as substantial weight loss, falls, and the use of specific medications including antibiotics, opioids, hypoglycemics, antiplatelets, and pain relievers. For example, one resident experienced a weight loss of over 20 pounds, but the MDS did not indicate a 10% or greater weight loss. Another resident had two documented falls, but the MDS assessment stated no falls had occurred during the relevant period. Additional deficiencies were noted in the failure to accurately document medication administration. Several residents received medications such as insulin, antibiotics, opioids, antiplatelets, and pain medications, but these were not captured in the corresponding MDS assessments. In one instance, a resident received both scheduled and PRN pain medications, as well as topical antibiotics, but the MDS failed to record these treatments. Similarly, another resident received a PPD injection for tuberculosis screening, which was not documented in the MDS. These inaccuracies were confirmed through interviews with MDS coordinators and review of medication administration records (MARs). The findings indicate that the facility did not consistently ensure that the MDS assessments accurately reflected the residents' clinical status and care provided during the assessment periods, as required by federal regulations.