Inaccurate Legal Name Coding on MDS Assessments for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate completion of the MDS assessments, specifically Section A0500 (Legal Name), for two residents. For one resident with diagnoses including pathological fracture in neoplastic disease, benign neoplasm of the left adrenal gland, cerebral palsy, and muscle weakness, the clinical record face sheet, census sheet, and insurance card reflected the resident’s preferred name, while the driver’s license and Medicare card showed the legal name. The admission and 5‑day MDS assessments correctly coded the legal name in A0500 and were accepted in QIES. After the resident was discharged to a group home, the discharge MDS documented a planned discharge to a home with organized home health services and return not anticipated, but A0500 was completed with the preferred name instead of the legal name. The discharge MDS was not modified to correct A0500 to the legal name until several months later. For another resident admitted with encephalopathy, polyneuropathy, and UTI, the face sheet showed a hyphenated last name, the insurance authorization form and State Medicaid eligibility information reflected part of the hyphenated last name, and the facility census list included the hyphenated last name. The facility profile form showed the resident’s legal last name. The admission and quarterly MDS assessments coded the legal last name, but the discharge MDS coded the hyphenated last name in A0500. The MDS Coordinator reported that Section A0500 is auto-populated from the electronic record, that she uses the electronic record, therapy notes, bedside assessments, and resident interviews to complete MDSs, and that she verifies resident identity by asking residents their name and preferred name. She stated she completed the admission MDSs for both residents using their legal names, did not complete the discharge MDSs, and did not know who did. The Corporate MDS Resource and DON confirmed that the system auto-populates the name field, that A0500 is intended for the legal name, and that the RAI manual requires coding the legal name as it appears on the Medicare card or other government-issued document.
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