Failure to Accurately Code Oxygen Therapy on Admission MDS Assessment
Penalty
Summary
The facility failed to accurately code an admission Minimum Data Set (MDS) assessment for a resident who was receiving continuous oxygen therapy. The resident was admitted with diagnoses including atrial fibrillation, coronary artery disease, and pneumonia, and had physician orders and a baseline care plan indicating continuous oxygen at 2 liters per minute. The Medication Administration Record (MAR) confirmed that oxygen therapy was administered on all shifts. However, the admission MDS assessment did not reflect the use of oxygen therapy, despite the resident being cognitively intact and receiving the therapy. The MDS Nurse acknowledged the omission, attributing it to an oversight during a transition to a new electronic health record system.