Inaccurate MDS Coding for Respiratory Therapy and Injections
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, resulting in deficiencies related to the assessment and documentation of care. For two residents, the MDS was coded to indicate that respiratory therapy was provided by a respiratory therapist or respiratory nurse, when in fact, the therapy consisted of nurses administering ultra-sonic nebulizer treatments. The nurses had only completed a brief online course and did not hold formal certification as respiratory nurses, nor did the facility employ a respiratory therapist. The minutes spent by these nurses administering the treatments were incorrectly counted as respiratory therapy on the MDS, contrary to the requirements outlined in the Resident Assessment Instrument User's Manual. Additionally, for another resident, the MDS was coded to reflect that an insulin injection was administered during the look back period. However, a review of the resident's medical record revealed there were no physician orders for insulin during that time. Instead, the resident had an order for Ozempic, a non-insulin injectable medication. Both the MDS Coordinator and the DON confirmed that this was a coding error and that the resident did not receive insulin. These inaccuracies in MDS coding were identified through record review and staff interviews.