Inaccurate MDS Coding for Active Diagnoses
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for two residents, resulting in deficiencies related to the documentation of active diagnoses. One resident was admitted and re-admitted with a diagnosis of paranoid schizophrenia, which was present on admission and supported by physician orders for antipsychotic therapy. However, the resident's quarterly MDS assessment did not include an active diagnosis of schizophrenia, despite the annual MDS and physician orders indicating its presence. The MDS Nurse reported that she was directed by the corporate office not to code schizophrenia on the MDS after the annual assessment, citing insufficient supporting documentation at the time of admission, and acknowledged that the annual MDS had been incorrectly coded to include the diagnosis. Another resident was admitted with a diagnosis of depression, but the admission MDS assessment incorrectly indicated a diagnosis of post-traumatic stress disorder (PTSD). A psychiatry evaluation confirmed that the resident did not have a history of PTSD, and the MDS Coordinator acknowledged this was a coding error. Both the DON and the Administrator confirmed their expectation that MDS assessments should be coded accurately. These inaccuracies in MDS coding were identified through record review and staff interviews.