Failure to Accurately Code Behavioral Symptoms on MDS Assessment
Penalty
Summary
The facility failed to ensure an accurate assessment for one resident when completing the annual MDS. The resident was admitted with diagnoses including major depressive disorder, anxiety disorder, hypertensive heart disease with heart failure, and adjustment disorder with depressed mood. The annual MDS with an ARD of 6/17/2025 coded Section E, Behavioral Symptoms, as 0, indicating that no behaviors were exhibited. However, review of the EMR showed that this coding did not reflect the resident’s documented behavioral status. The EMR contained a behavior note dated 06/11/2025 describing the resident as very hostile and disoriented, incontinent in bed, and expressing paranoid statements that people were hiding things from her. The note further documented that the resident went behind the nurses’ station, took cigarettes and a lighter despite a CNA telling her not to, lit a cigarette, walked down the hall smoking, and became very hostile when the Administrator and Charge nurse attempted to take the lit cigarette from her, cursing before returning to her room. During interviews, the MDS Coordinator confirmed that this behavior note should have been reflected in Section E of the annual MDS, and the DON and MDS Coordinator acknowledged that accurate coding of behaviors in Section E would trigger the need for development of a new care plan. The Administrator stated that the facility does not have a specific internal MDS policy and relies on the RAI Manual for guidance.
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