Inaccurate Coding of PASARR Status and Oral/Dental Status on MDS Assessments
Penalty
Summary
The facility failed to accurately code the Pre-admission Screening and Resident Review (PASARR) status and the Minimum Data Set (MDS) assessment for two residents. For one resident with diagnoses including schizophrenia, major depressive disorder, and anxiety disorder, the PASARR Level II Determination Notification indicated an ongoing status with no end date. However, the resident's MDS assessment was incorrectly coded as not currently considered by the state PASARR Level II process to have a serious mental illness. Staff interviews confirmed the error and acknowledged it was an oversight. For another resident, the nursing admission observation documented obvious or likely cavities or broken natural teeth, and the resident was observed to have multiple broken and discolored teeth. Despite this, the resident's admission MDS assessment did not reflect any dental issues, and the dental care area was not triggered. The staff member responsible for coding the oral/dental section of the MDS did not recall reviewing the nursing admission assessment or directly observing the resident's teeth. The DON confirmed the resident had broken and discolored teeth since admission, and the MDS assessment should have accurately reflected this condition.