Failure to Accurately Document Oxygen Use in MDS Assessment
Penalty
Summary
The facility failed to accurately document a resident's Minimum Data Set (MDS) assessment, specifically omitting the resident's use of oxygen therapy. The resident, who had a history of cellulitis, sepsis, and contractures, was noted in the physician order summary to have an order for oxygen as needed at 2 liters per minute. Medical records showed that the resident received oxygen on multiple dates within the MDS assessment reference period. During an interview and record review, the MDS Coordinator confirmed that the MDS submitted did not reflect the resident's oxygen use, acknowledging this as a miscoding error. The Director of Nursing also stated that inaccuracies in the MDS could result in the resident not receiving appropriate services or treatment. Facility policy requires that resident assessments accurately depict and identify resident-specific issues and objectives.