Inaccurate MDS Coding for Behavior and Medication Administration
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, as identified through record review, reference to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, and staff interviews. For one resident, the quarterly MDS was coded to indicate the presence of delusions during the seven-day look-back period; however, a review of the medical record for that period did not show any evidence that the resident experienced delusions. This discrepancy indicates that the MDS did not accurately reflect the resident's behavioral status as required by the RAI manual. For another resident, the significant change MDS was coded to show that the resident received an injection once during the seven-day look-back period. However, the medical record did not support that any injection was administered during that time. An administrative staff member confirmed that the MDSs for both residents were coded incorrectly. These inaccuracies in MDS coding could result in assessments that do not accurately represent the residents' current status and needs.