F0641

B

Inaccurate MDS Coding for Non-Invasive Ventilator Use

Canonsburg, Pennsylvania Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) assessments accurately reflected the actual use of non-invasive mechanical ventilation for two residents. For one resident with diagnoses including diabetes, obstructive sleep apnea, and renal insufficiency, the MDS section O0110 G1 documented that a non-invasive mechanical ventilator was not in use. However, the clinical record showed a physician’s order for CPAP with 4 liters of oxygen every evening and night for obstructive sleep apnea, a care plan specifying oxygen at 4 liters per minute to the CPAP device, and a treatment administration record indicating BiPAP use over a specified period. During an interview, this resident reported using the CPAP machine every night, and the Director of Nursing confirmed that the MDS did not indicate CPAP or BiPAP use as required.

For the second resident, who had diagnoses of diabetes, obstructive sleep apnea, and COPD, the MDS section O0110 G1 also documented that a non-invasive mechanical ventilator was not in use. In contrast, the clinical record contained a physician’s order for BiPAP use at bedtime for obstructive sleep apnea, a care plan describing BiPAP settings and oxygen bleed, and a treatment administration record showing BiPAP administration over a specified period. During an interview, the resident’s BiPAP mask was observed on the floor next to the bed, and the resident stated she tried to use her BiPAP but could not put the mask on herself and that nursing staff did not come in often to assist with applying the mask. The Director of Nursing confirmed that the facility failed to ensure MDS assessments accurately reflected these residents’ status, in violation of 28 Pa. Code 211.12(c)(d)(5) Nursing services.