Inaccurate MDS Assessment of Oxygen Therapy
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment for a resident accurately reflected the resident's use of oxygen therapy. The resident, who had diagnoses including dementia and anemia and lacked decision-making capacity, was admitted with orders for oxygen therapy as needed for shortness of breath, with specific parameters for administration and monitoring. Despite these orders and daily documentation of oxygen use throughout the assessment period, the MDS assessment did not indicate that the resident was receiving oxygen therapy, and was coded as if no oxygen was used. Observations and interviews confirmed that the resident was consistently on oxygen, except during showers, and this was corroborated by nursing staff and daily vital sign records. The MDS Coordinator acknowledged failing to review the oxygen saturation summary data, which would have shown daily oxygen use during the look-back period. The facility's policy required accurate completion and attestation of the MDS, but this was not followed, resulting in inaccurate reporting to CMS regarding the resident's respiratory treatments.