Inaccurate MDS Coding for Medications, Diagnoses, and Treatments
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for four residents in several key areas, including medication use, oxygen therapy, prognosis, and active diagnoses. For one resident with heart failure and pulmonary embolism, the MDS assessment incorrectly documented that the resident was not taking anticoagulant medications and was taking antibiotics, despite physician orders and medication administration records confirming ongoing warfarin therapy and no antibiotic prescriptions. The MDS nurse acknowledged this was a data entry error, having mis-keyed the information despite her own worksheet reflecting the correct medication. Another resident with chronic respiratory failure and chronic obstructive pulmonary disease was not coded for oxygen use on the MDS assessment, even though physician orders and medication records showed continuous oxygen therapy during the assessment period. The MDS nurse confirmed this omission was an oversight after reviewing the resident's orders and medication records. Similarly, a resident receiving hospice care for vascular dementia was not coded on the MDS for having a condition with a life expectancy of less than six months, despite a valid hospice certification and ongoing hospice care. The nurse responsible for the MDS assessment admitted this was also an oversight. Additionally, a resident with documented diagnoses of dementia and hypertension was not coded for these conditions on the MDS assessment, even though both diagnoses were active, included in the care plan, and supported by clinical documentation and vital sign monitoring. The MDS nurse stated she did not see the relevant documentation in the electronic medical record during the look-back period, resulting in the omission. In each case, the administrator confirmed that accurate MDS coding was expected.