Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for several residents, as identified through record review, reference to the RAI User's Manual, and staff interviews. Specific deficiencies included not identifying a serious mental illness for a resident with a qualifying PASRR Level II screening, incorrectly coding a resident's discharge location as a nursing home instead of home, and omitting an active diagnosis of depression for a resident receiving antidepressant medication. Additionally, a resident admitted to hospice care was not coded as terminally ill or as receiving hospice services on the MDS, and another resident's application of dressings to lower extremity wounds was not documented in the MDS despite treatment records confirming the care was provided. These inaccuracies in MDS coding were confirmed by an administrative nurse and were found across multiple sections, including identification information, active diagnoses, health conditions, skin conditions, and special treatments. The errors were substantiated by medical records, physician orders, treatment administration records, and progress notes, all of which demonstrated discrepancies between the care provided or resident status and what was documented in the MDS assessments.