Inaccurate MDS Coding for Mobility and Pain Management
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one resident, resulting in multiple discrepancies between the resident's actual condition and the documented assessment. The resident, who was admitted with diagnoses including an absence of the left leg below the knee, chronic pain, and type 2 diabetes mellitus, was incorrectly coded in several MDS sections. Specifically, the MDS indicated that the resident used a walker for mobility, while interviews with the resident and staff confirmed that the resident used a wheelchair and rarely got out of bed. The Regional Nurse Consultant also confirmed that the MDS coding did not accurately reflect the resident's use of a wheelchair. Further review revealed that the MDS was incorrectly coded regarding the resident's pain management and medication use. Although the resident had a physician's order for scheduled Hydrocodone-Acetaminophen and received this opioid medication routinely during the look-back periods, the MDS was coded to indicate that the resident did not receive scheduled pain medication and was not taking an opioid. These inaccuracies were confirmed through interviews and review of the resident's medication administration records and physician orders.