Inaccurate Resident Assessments and MDS Coding
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status for three residents. For one resident with Parkinson's disease and weakness, clinical record review and observation revealed the use of a right-sided enabler bar, which the resident used for mobility in bed. However, the resident's quarterly MDS assessments were incorrectly coded as restraint use related to enabler bars, contrary to the actual use and physician orders for the device as an enabler. Another resident with a diagnosis of adjustment disorder and a history of trauma related to witnessing a choking incident had a care plan that included trauma-informed care and counseling services. Despite documentation in psychology consults indicating significant focus on grief and loss, the resident's quarterly MDS assessment failed to document PTSD, which was relevant to her care needs and supported by her clinical history and care plan. A third resident with hemiplegia was observed with a right-side enabler bar in the room, and physician orders supported its use for bed mobility and independence. However, the resident's quarterly MDS was also incorrectly coded for restraint use related to enabler bars, not reflecting the actual purpose and physician orders for the device. These inaccuracies in the MDS assessments were confirmed by the Nursing Home Administrator, who acknowledged the errors in coding and the need for modification.
Plan Of Correction
1. R 4 and R 14's Minimum Data Set (MDS) were modified on 12/9/25 to accurately reflect that a restraint was not in use. R 12's medical record was reviewed, and no PTSD diagnosis has been identified by the provider. R 12 does have a trauma history which has been care planned, and the CMS 802 roster was updated to reflect the history of trauma on 12/9/25. The provider will be notified to evaluate if a post-traumatic stress disorder (PTSD) diagnosis is warranted. 2. An audit was completed on 12/9/25 for current residents coded as restraints on Section 0 of the MDS, and modifications were completed as necessary. An audit was completed on 12/9/25 to identify residents with a history of trauma and/or PTSD diagnosis. The 802 was manually updated to indicate the history of trauma for identified residents, but no PTSD diagnoses were identified in any resident. No modifications to MDS accuracy were identified. The physician/provider will be notified to review identified residents to evaluate if a PTSD diagnosis is warranted. 3. The RNACs will be re-educated by the Executive Director on proper coding and accuracy of the MDS in its entirety with a focus on proper coding of restraints at Section O. In addition, education will be provided by the Executive Director to the RNACs that PTSD requires a physician diagnosis to be coded in Section I of the MDS and that the 802 rosters should be checked for PTSD diagnosis or identified history of trauma. The 802 roster will be submitted to DON weekly for review of accuracy of triggered items. The Interdisciplinary team completing sections of the MDS will be re-educated on accuracy of coding the MDS by the Executive Director. 4. The Director of Nursing or designee will conduct weekly audits of at least 5 residents per week for 12 weeks to validate accurate coding of Section 0 for restraints and Section I for PTSD. Audits will include at least 1 MDS per week for 12 weeks reviewed in its entirety for accuracy. Findings of audits will be analyzed to identify/track trends or patterns and will be reported to the facility Quality Assurance/Performance Improvement Committee for review and/or recommendation.