Inaccurate MDS Coding and Pain Assessment Documentation for Multiple Residents
Penalty
Summary
The deficiency involves inaccurate completion of Minimum Data Set (MDS) assessments for multiple residents. One resident experienced a change in condition when two GNAs were transferring the resident from bed to wheelchair, the resident’s knees buckled, and the resident was lowered to the floor. A change in condition evaluation documented this witnessed fall, but the subsequent Discharge – Return Anticipated MDS assessment did not code the fall in Section J. Another resident had a physician order for admission to Hospice and an active Hospice care plan, yet the Quarterly MDS assessment did not code the resident as receiving Hospice services in Section O. Additional inaccuracies were identified in MDS coding related to influenza vaccination status. One resident’s medical record showed that the resident received the influenza vaccine in the facility, but the MDS assessment documented that the resident had not received the vaccine and that it was “not offered.” Another resident’s immunization record documented that the resident had refused the influenza vaccine on admission, with education provided on risks and benefits, and also showed in historical data that the resident had already received the influenza vaccine for the current season. However, the MDS assessment coded that the resident had not received the vaccine and that it was “offered and declined,” failing to reflect the documented administration in historical data. A further deficiency was identified in the assessment and documentation of pain for a resident with a long-standing diagnosis of rheumatoid arthritis who reported being in constant pain and stated that they had informed staff of their pain intensity. The resident had a standing order for Hydrocodone-Acetaminophen every eight hours with a requirement to record pain level on the MAR using a 0–9 scale, but the MAR showed inconsistent pain level entries, numerous “0” pain scores despite the resident’s report of never being without pain, and instances where pain level was not recorded at all. Skilled Nursing Charting PDPM entries also indicated that the resident reported no pain, which conflicted with the resident’s statements. The resident additionally had a PRN order for Extra Strength Tylenol for chronic pain, which was administered only once during the first two weeks of the month, despite the resident’s report of requesting pain medication almost daily.
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