Failure to Accurately Code MDS Assessments for Respiratory and IV Treatments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status and treatments of three residents. Specifically, the MDS assessments for these residents did not properly code for the use of BiPAP/CPAP treatments, and in one case, did not code for a PICC line as ordered by the physician. Observations revealed that BiPAP/CPAP masks were not stored or cleaned according to physician orders, with masks found on the floor, on nightstands, or in drawers unbagged, and residents reported that staff had not cleaned or bagged their equipment. The MDS coordinator stated that coding for a non-invasive mechanical ventilator was considered sufficient, but specific sections for BiPAP and CPAP were left blank, and the PICC line was not documented as required. The residents involved had significant medical histories, including chronic heart failure, obstructive sleep apnea, COPD, osteomyelitis, sepsis, asthma, and chronic respiratory failure. All three residents were cognitively intact and required varying levels of assistance with activities of daily living. Physician orders and care plans indicated the need for BiPAP/CPAP treatments and, in one case, a PICC line for IV antibiotic therapy. However, these treatments were not consistently documented in the MDS assessments, and care plans did not always address the respiratory equipment or IV therapy as required. Interviews with facility staff, including the MDS coordinator and DON, confirmed that the responsibility for accurate and timely completion of MDS assessments rested with the MDS coordinator, with RN review for accuracy. Despite this, the assessments were not completed accurately to reflect the residents' care and treatments. The facility's policy for conducting accurate assessments was requested but could not be reviewed due to technical issues with the electronic copies provided.