Inaccurate MDS Coding for Diagnoses and Special Treatments
Penalty
Summary
The facility failed to accurately complete sections I (active diagnoses) and O (special treatments and programs) of the Minimum Data Set (MDS) for four of fourteen sampled residents. Specifically, two residents who were admitted to hospice care were not coded as receiving hospice services in Section O of their MDS assessments, despite orders and documentation confirming their hospice status. Additionally, two other residents were incorrectly coded as having a diagnosis of bipolar disorder in Section I of their MDS, even though their medical records and hospital problem lists did not support this diagnosis. These inaccuracies were confirmed by the Director of Nursing, who acknowledged that the assessments did not reflect the residents' actual health status at the time of completion. The residents affected included individuals with severe cognitive impairment, advanced dementia, Alzheimer's disease, cerebrovascular accident history, and other significant medical conditions. The errors in MDS coding were identified through staff interviews and record reviews, which revealed discrepancies between the residents' documented diagnoses and treatments and what was reported in the MDS. The Director of Nursing confirmed that the assessments should have been completed accurately and that the facility failed to ensure the correctness of the submitted MDS data for these residents.