Inaccurate MDS Coding for Medications, Falls, and Discharge
Penalty
Summary
The facility failed to accurately complete and encode Minimum Data Set (MDS) assessments for two residents, resulting in deficiencies related to antipsychotic medication administration, fall reporting, and discharge documentation. For one resident, the MDS Coordinator incorrectly documented that the resident had not received antipsychotic medication since admission, despite physician orders and medication administration records confirming daily administration of Quetiapine. Additionally, the same resident experienced a fall resulting in a right humerus fracture, but the MDS was coded to indicate a non-major injury, omitting the fracture. The MDS Coordinator stated that she relied on incomplete information from the electronic medical record and missed the documentation of the fracture, leading to inaccurate MDS coding. Another resident was sent to the hospital and died there after more than 24 hours, but the MDS Coordinator completed a 'Death in Facility' assessment instead of the required 'Discharge with Return Anticipated' assessment. The Coordinator referenced the CMS RAI User's Manual, which specifies that a discharge assessment is required if a resident is in the hospital for observation for more than 24 hours, regardless of admission status. The Coordinator acknowledged the error after reviewing the timeline and documentation, confirming that the incorrect MDS assessment was completed.