Inaccurate MDS Coding for Refusals and Chronic Scalp Wound
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected resident status for two residents reviewed for skin issues. For one resident with diagnoses including diabetes mellitus, heart failure, and morbid obesity, the quarterly MDS dated 09/29/2024 documented intact cognition and no behaviors, including no refusals of care, medications, or activities of daily living. However, nursing notes showed that this resident refused an IV catheter for IV infuvite on 09/23/2024 and refused milk of magnesia on 09/27/2024, stating they had not eaten in days. Additional documentation on 09/27/2024 described the resident as aggressive/combative and resisting/refusing care. The September Medication Administration Record showed refusals of Eliquis on 09/22/2024, 09/24/2024, and 09/25/2024, and CNA ADL documentation for September 2024 recorded behavior symptoms on multiple dates. Despite these documented refusals and behaviors, they were not captured on the MDS, and the Regional MDS Coordinator later acknowledged that these behaviors should have been included and that information may have been entered incorrectly by new staff. For a second resident with diagnoses including urinary abscess of the head/scalp, unspecified open wound of the head, and chronic osteomyelitis of the skull, the MDS assessments also failed to accurately reflect the resident’s condition. A physician’s note dated 11/26/2025 documented a chronic right scalp infection with greenish-brown exudate, and physician orders on 11/26/2025 and 11/27/2025 directed cleansing of the right temporal area with normal saline, application of a clean dry dressing, and topical Gentamicin Sulfate for osteomyelitis of the scalp. The Treatment Administration Record showed that the ordered scalp treatment was administered on 12/30/2025 and 12/31/2025. Despite this, both the Five-Day and Quarterly MDS assessments documented that the resident did not have other ulcers, wounds, or skin problems. The Regional MDS Coordinator stated that staff entering the MDS information made mistakes, that the MDS Coordinator position had been vacant, and that corporate staff were attempting to complete assessments while the Regional Coordinator was overseeing them but having difficulty keeping up.
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