Inaccurate MDS Coding for Clinical Treatments and Medications
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for four residents, resulting in discrepancies between clinical documentation and MDS entries. For one resident with a history of urinary tract infection and benign prostatic hyperplasia, the MDS did not reflect the presence of an intravenous (IV) line, despite physician orders and documentation confirming IV access and maintenance during the assessment period. Another resident with liver disease, dementia, and major depressive disorder was incorrectly coded as receiving an antipsychotic medication and not an antidepressant, even though physician orders and medication administration records showed daily administration of an antidepressant and no antipsychotic use. A third resident with anxiety disorder and PTSD was administered anti-anxiety medication on two occasions during the MDS look-back period, but the MDS failed to indicate any anti-anxiety medication use. The fourth resident, dependent on renal dialysis and diagnosed with end-stage renal disease, was regularly transported for dialysis treatments as documented in physician orders and medication administration records, yet the MDS did not indicate receipt of dialysis treatment. In each case, the MDS Nurse acknowledged during interviews that the assessments were coded incorrectly and did not accurately reflect the residents' clinical status or treatments received during the relevant periods.