Inaccurate MDS Coding for Medications, Treatments, and Discharge Status
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) Assessments for six residents, resulting in multiple discrepancies between clinical documentation and MDS entries. For example, one resident with a history of diabetes was administered insulin daily as ordered by the physician, but the MDS assessment did not reflect any insulin administration or injections during the observation period. Another resident with a longstanding callous that developed into a pressure ulcer upon admission was not coded as having a pressure injury present on admission, despite clinical notes and wound care documentation indicating otherwise. Additional inaccuracies included a resident who was coded as receiving an anticoagulant during the MDS lookback period, although there were no physician orders or medication administration records supporting this. Another resident, who was observed and ordered to receive continuous oxygen therapy, was incorrectly coded as not utilizing oxygen on the MDS assessment. Furthermore, a resident with a documented stage 3 pressure area during the observation period was not coded for any pressure injuries on the MDS, despite ongoing wound care treatments documented in the clinical record. Finally, a discharge MDS assessment was completed for a resident indicating discharge to an acute hospital, while clinical progress notes confirmed the resident was actually discharged home. These coding errors were confirmed through interviews with the MDS nurse and other clinical staff, who acknowledged the inaccuracies in the MDS assessments compared to the residents' clinical records and care provided.