Inaccurate MDS Coding for Hospice Status and Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected residents' current diagnoses and medical conditions for two residents. For one resident, progress notes from early November documented that the resident was receiving hospice services and wound treatments to the foot, and a wound consultant note from late October identified arterial ulcers on multiple toes of the right foot. However, the resident’s Significant Change MDS dated in mid-November did not include coding for hospice services or the vascular (arterial) wounds. The Assessment Coordinator later confirmed that these conditions were not coded on that Significant Change MDS. For another resident, the quarterly MDS documented a BIMS score indicating moderate cognitive impairment and listed diagnoses of anxiety and suicidal ideation, but did not reflect the resident’s diagnosis of schizophrenia. The clinical record showed that the resident had documented diagnoses of schizophrenia, alcohol use, suicidal ideation, and anxiety disorder, and physician orders indicated ongoing treatment for schizophrenia with antipsychotic medications since admission. The physician records further confirmed that the resident was actively being treated for schizophrenia. In an interview, the Assessment Coordinator acknowledged that the resident had a schizophrenia diagnosis but stated it had been removed from the MDS based on facility criteria following a CMS audit, and was unable to provide the guidelines or explain how that determination was made.
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