Inaccurate MDS Coding for Discharge, Hospice, and Oxygen Use
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for three residents. One resident was discharged to an assisted living facility, but the discharge MDS was incorrectly coded as a discharge to a hospital. The MDS Coordinator, who was new to the role, acknowledged the error and stated that the discharge status should have reflected the actual destination. Both the DON and Administrator confirmed that the MDS should be coded accurately, but were unaware of the reason for the incorrect coding. Another resident was admitted to hospice services prior to admission, but the admission MDS did not reflect hospice care due to an oversight by the MDS Coordinator. Additionally, a third resident with a history of CVA, hemiplegia, and oxygen dependence was not coded for oxygen use on the quarterly MDS assessment, and their functional status was inaccurately documented. Staff interviews confirmed the resident's dependence on oxygen and total care needs, but these were not accurately captured in the MDS. The Administrator and clinical staff indicated that information from therapy, nursing, and physician orders should be used for accurate MDS coding.