Inaccurate Coding of Oxygen Therapy on MDS Assessment
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were coded accurately for one resident. Medical record review showed that the resident was admitted with diagnoses including cerebral infarction, COPD, dementia, and anxiety disorder. Physician orders indicated the resident was to receive oxygen therapy as needed to maintain oxygen saturation above 92%. However, review of the MDS assessment did not reflect the resident's use of oxygen therapy in section O, which documents special treatments and procedures. This discrepancy was confirmed by the MDS Coordinator, who acknowledged that the assessment was not coded correctly. Facility policy requires that licensed nurses accurately complete and certify each section of the MDS assessment.