Inaccurate MDS Coding for Diabetes and Anxiety Diagnoses
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident by not correctly coding documented diagnoses of diabetes and anxiety. The resident, who had a medical history significant for type 2 diabetes mellitus and generalized anxiety disorder, was care planned for diabetes but not for anxiety. A physician encounter note documented diet-controlled diabetes mellitus, and a physician order directed administration of Ativan 0.5 mg once daily in the evening for anxiety and an unspecified mood disorder. Despite this documentation and the resident being coded on the annual MDS as cognitively severely impaired and receiving an antianxiety medication, the annual MDS did not include diabetes or anxiety as active diagnoses. In interviews, the MDS nurse acknowledged that these diagnoses were present and should have been coded on the annual MDS, stating that their omission was an oversight, and the Administrator confirmed that all resident diagnoses, including diabetes and anxiety, should have been reflected on the MDS.
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