Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, resulting in deficiencies related to the management of care. For one resident, observations revealed signage and personal protective equipment indicating Enhanced Barrier Precautions (EBP) due to a history of multiple drug-resistant organisms (MDRO) in the urine. The resident's care plan documented EBP for MDRO and insulin therapy for diabetes, and the Medication Administration Record showed insulin administration during the assessment period. However, the quarterly MDS did not reflect the resident's history of MDRO or insulin use in the relevant sections. For another resident, a review of the medical record and care plan indicated a diagnosis of hypertensive heart disease and dementia, with a severely impaired cognitive status. The admission MDS documented no falls in the 2-6 months prior to admission, but the baseline care plan and other documentation noted a fall in the relevant period as reported by the resident's daughter. Additional assessments identified the resident as being at risk for falls due to an unsteady gait. The discrepancies between the MDS coding and supporting documentation contributed to the deficiency.