Inaccurate MDS Assessments Across Multiple Clinical Areas
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for eight residents, resulting in multiple inaccuracies across several assessment areas. These inaccuracies included incorrect coding of Preadmission Screening and Resident Review (PASARR) status, discharge status, bowel continence, oxygen use, medication administration, urinary catheter use, and bowel patterns. For example, one resident with a documented Level II PASARR and diagnoses of serious mental illness was not coded appropriately in the MDS, and another resident's discharge status was incorrectly recorded as a hospital discharge instead of a discharge to home, despite progress notes indicating otherwise. Further review revealed discrepancies between clinical documentation and MDS coding for bowel continence, oxygen therapy, and medication administration. One resident was documented as incontinent of bowel every day during the look-back period, yet was coded as always continent in the MDS. Another resident was receiving continuous oxygen therapy according to nursing notes, but this was not reflected in the MDS. Additionally, several residents were inaccurately coded for receiving injections, insulin, antibiotics, opioids, or antianxiety medications, despite medication administration records and physician orders showing otherwise. The facility also failed to accurately code the use of urinary catheters and the presence of constipation for a resident with a physician order for Foley catheter output monitoring and documented infrequent bowel movements. Interviews with staff, including the MDS Coordinator and Director of Nursing, confirmed that the MDS assessments were not completed accurately in these cases, and staff acknowledged the discrepancies between the clinical records and the MDS coding.