Inaccurate MDS Coding for PASARR Status, Medication, and Falls
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents in the areas of Pre-admission Screening and Resident Review (PASARR) status, medication administration, and falls. For one resident with a history of cerebral infarction, the MDS assessment did not reflect her current Level II PASARR determination, despite documentation and staff acknowledgment that she had an active Level II PASARR status. Another resident with a history of cerebrovascular accident was not coded as receiving antiplatelet medication on the MDS, even though physician orders and medication administration records confirmed daily administration of Aspirin, an antiplatelet agent. Staff interviews confirmed these coding errors were due to oversight. A third resident, admitted with a progressive neurological condition, was also incorrectly coded on the MDS as not having a Level II PASARR determination, despite documentation to the contrary. Additionally, this resident experienced a fall resulting in a laceration and hospital visit, but the incident was not captured in the discharge MDS assessment. Staff interviews revealed that the fall should have been documented in the MDS, but was missed. In each case, staff and administration acknowledged that the MDS assessments were not coded accurately, as required.