Inaccurate MDS Coding for Oxygen Therapy and Discharge Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents in the areas of respiratory treatment and discharge location. One resident, admitted with chronic obstructive pulmonary disease (COPD) and requiring continuous supplemental oxygen as documented in both the hospital referral form and nursing progress notes, was not coded for oxygen therapy on the admission MDS. The MDS Coordinator acknowledged reviewing the relevant documentation but stated that the omission was a mistake during the assessment process. Both the Director of Nursing (DON) and the Administrator confirmed that the MDS should be coded accurately but were unable to explain the cause of the error. Another resident, who had a planned discharge to home with home health services, was incorrectly coded on the discharge MDS as discharged to home/community rather than under the care of an organized home health service organization. The MDS Coordinator reported routinely coding discharges to home as home/community and was unaware of the correct coding for discharges involving home health services, despite documentation in the social service progress note. The DON and Administrator both stated that the MDS should be coded accurately but could not provide reasons for the incorrect coding.