Inaccurate MDS Coding for Non-Invasive Mechanical Ventilator Use
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded regarding the use of a non-invasive mechanical ventilator for a resident. According to facility policy, all portions of the MDS must be certified for accuracy and reflect the resident's status during the observation period. The resident in question had a medical history including heart failure, COPD, sleep apnea, lobar pneumonia, and dependence on supplemental oxygen. The quarterly MDS assessment indicated that the resident received oxygen therapy but did not use a non-invasive mechanical ventilator, despite documentation to the contrary. Review of the resident's Treatment Administration Record (TAR) showed that a CPAP, which is a non-invasive mechanical ventilator, was ordered and administered during the 14-day look-back period for the MDS assessment. Staff documented the use of the CPAP on multiple occasions within this period. Interviews with the DON and Administrator confirmed that the use of CPAP should have been included in the MDS assessment and that accurate documentation and observation are essential for proper coding. The failure to capture the use of the non-invasive mechanical ventilator on the MDS assessment constituted the deficiency.