Inaccurate MDS Coding for Medications, PASRR Status, Range of Motion, and Admission Source
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for multiple residents in several key areas, resulting in deficiencies. For one resident with diabetes and cirrhosis, the MDS did not reflect the administration of an antibiotic (rifaximin) during the 7-day look-back period, despite documentation in the Medication Administration Record and confirmation by MDS staff that the medication was given. Another resident who was hospitalized for sepsis and re-entered the facility was incorrectly coded as having entered from another nursing home, rather than from a hospital, due to reliance on pre-populated fields and lack of verification by the Social Service Director. A resident with schizoaffective disorder and a PASRR Level II determination was not accurately coded on the MDS to reflect this status, even though the care plan and PASRR documentation confirmed the requirement for specialized services. The MDS nurse acknowledged the omission, attributing it to assessments being completed by remote staff. Additionally, a resident with dementia and contractures was incorrectly coded as having no upper extremity impairment, despite care plan documentation and direct observation of contractures in the left hand and wrist. The MDS nurse admitted this was an oversight, and the administrator confirmed the coding error regarding range of motion. These inaccuracies were identified through staff interviews, record reviews, and direct observation, affecting four out of twenty-one residents whose MDS assessments were reviewed. The deficiencies involved failure to accurately document antibiotic use, PASRR Level II status, range of motion impairment, and the correct discharge location prior to admission or re-entry, as required by regulatory standards.