Inaccurate MDS Coding for Diagnoses and Medication Management
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents. For one resident with diagnoses including dementia, encephalopathy, and bipolar disorder, the MDS was inaccurately coded to indicate that a gradual dose reduction (GDR) of antipsychotic medication was clinically contraindicated, based on documentation from a psychiatric nurse practitioner. However, review of the nurse practitioner's notes did not support that a GDR was clinically contraindicated, and the MDS nurse acknowledged that the notes used were not appropriate for coding the MDS. Additionally, another resident with vascular dementia, hemiplegia, anxiety disorder, and depressive disorder had multiple MDS assessments that failed to include the diagnoses of anxiety and depression, as the MDS nurse was unaware of these diagnoses. A third resident with a history of stroke and dementia had an MDS assessment that inaccurately coded the presence and development of pressure injuries, with the MDS nurse confirming the inaccuracy. These findings were based on record reviews and staff interviews.