Inaccurate MDS Coding for Resident Assessments and Discharges
Penalty
Summary
Surveyors identified deficiencies related to the facility's failure to ensure accurate assessments for multiple residents, as required by policy and federal guidelines. For one resident with a history of orthopedic aftercare, bilateral lower limb amputations, and dementia, the Minimum Data Set (MDS) was inaccurately coded regarding falls with major injury. The resident experienced a fall resulting in abrasions to the right stump, but the MDS did not accurately reflect the absence of a major injury. Both the MDS Coordinator (MDSC) and Director of Nursing (DON) confirmed that the MDS was not coded correctly, which could misrepresent the resident's clinical status and care needs. Another resident with diagnoses including psychosis, dementia, and muscle wasting was inaccurately coded on the MDS as having an active diagnosis of schizophrenia, despite the admission record and psychiatrist's progress note not supporting this diagnosis. The MDSC acknowledged the error, noting that the inaccurate coding could cause confusion regarding the resident's status and potentially delay appropriate care and services. The DON also confirmed that the MDS should have accurately reflected the resident's diagnoses to ensure proper care planning. A third resident, admitted with Alzheimer's disease, history of falls, and major depressive disorder, was discharged to home with home health services. The MDS was coded as an unplanned discharge, although records indicated the discharge was planned and coordinated with appropriate referrals and services. The MDSC and DON both stated that the discharge should have been coded as planned, as the resident was prepared for discharge in advance. The facility's policy required that assessments accurately depict resident-specific issues and objectives, which was not met in these cases.