Inaccurate MDS Assessments and Medication Coding
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for nine out of 26 residents reviewed. Specifically, for several residents who were able to make themselves understood and were able to understand others, the MDS assessments were coded to indicate that a Brief Interview for Mental Status (BIMS) and a mood interview should be conducted. However, the corresponding sections for these assessments (Sections C0200-C0500 for BIMS and Section D0150 for mood interview) were left as not assessed, despite the residents' ability to participate in these interviews. This was confirmed through review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, which indicated that these sections should have been completed for residents who were at least sometimes understood. Additionally, the facility failed to accurately code the administration of antibiotic medications in the MDS assessments for three residents. Physician's orders and Medication Administration Records (MARs) showed that these residents received antibiotics during the seven-day look-back period, but the MDS assessments were coded to indicate that no antibiotics were administered. This discrepancy was confirmed by the Nursing Home Administrator, who acknowledged that the MDS assessments did not reflect the actual administration of antibiotics as required by the RAI User's Manual. The deficiencies were identified through a review of clinical records, MDS assessments, and staff interviews, which revealed that required assessment sections were either not completed or inaccurately coded. The failure to accurately complete and code the MDS assessments resulted in incomplete documentation of residents' cognitive status, mood, and medication administration during the assessment periods.