Inaccurate MDS Assessment Due to Miscoding of Resident's Level of Consciousness
Penalty
Summary
Facility staff failed to complete an accurate Minimum Data Set (MDS) assessment for one resident. Specifically, the resident's quarterly MDS was incorrectly coded to indicate a persistent vegetative state with no discernable consciousness, despite clinical records and progress notes showing that the resident was never in such a state during their stay. This miscoding in Section B of the MDS led to the omission of responses in subsequent sections related to cognition, mood, and behaviors. The error was made by the LPN serving as the MDS coordinator, who acknowledged the mistake during an interview and confirmed that the resident was never in a persistent vegetative state. The coding instructions from the RAI manual were not followed, as there was no documented diagnosis of coma or persistent vegetative state during the required look-back period. The deficiency was identified through staff interviews and clinical record review, and facility leadership was informed of the findings.