Inaccurate MDS Coding for PASRR Level II and Pressure Wound
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents in the areas of Preadmission Screening and Resident Review (PASRR) Level II and pressure wounds. For one resident with a diagnosis of bipolar disorder, the electronic health record contained a PASRR Level II determination, but the annual MDS was incorrectly coded as Level I. Staff interviews confirmed this was a human error. Similarly, another resident with bipolar disorder had a PASRR Level II determination in the health record, but the annual MDS was also incorrectly coded as Level I, which staff attributed to a coding error. Additionally, a resident with vascular dementia and hemiparesis was incorrectly coded on the quarterly MDS as having a stage 1 pressure ulcer, even though the pressure ulcer developed after the assessment date. Staff interviews confirmed that the resident did not have a pressure wound at the time of the MDS assessment and that the coding was an input error. The administrator acknowledged that the MDS should accurately reflect the resident's conditions and that these were errors.