Inaccurate MDS Coding for Respiratory Treatment and PASRR Mental Illness Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected residents’ conditions and services for two residents. One resident was admitted with multiple diagnoses including dementia, Parkinson’s disease, kidney failure, and obstructive sleep apnea. The resident used a CPAP machine for respiratory support and, according to the Interim DNS, had never required an invasive mechanical ventilator. However, the resident’s Quarterly MDS dated 11/1/25 documented “yes” at item F1 in Section O, indicating use of an invasive mechanical ventilator. The MDS Coordinator later stated that this item had been marked “yes” in error, confirming that the assessment did not accurately represent the resident’s actual respiratory treatment. Another resident was admitted with multiple diagnoses including heart disease, bipolar disorder, depression, and anxiety. The resident’s record contained an Abbreviated Level 2 PASRR dated 12/10/25, which documented at item 33 that the individual had a current diagnosis of severe mental illness per PASRR criteria, listing bipolar disorder, depression, and anxiety. Despite this, the resident’s Admission MDS dated 12/17/25 documented “no” at item A1500, which asks whether the resident is currently considered by the state Level 2 PASRR process to have a serious mental illness and/or intellectual disability or related condition. The MDS Coordinator stated she was not aware that item 33 on the PASRR Level 2 form needed to be reflected on the MDS and acknowledged that the Admission MDS was not accurate for this resident.
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