Inaccurate MDS Coding for Restraints and PASRR Level II Status
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for two of three residents reviewed, resulting in inaccurate transmission of assessment data. For one resident admitted with anxiety, depression, and a need for assistance with personal care, a Quarterly MDS dated [DATE] documented in Section P0100 that physical restraints were used in a chair or in bed less than daily, although the DON later confirmed this coding was inaccurate. For another resident admitted with hemiplegia/hemiparesis, COPD, ESRD, depression, bipolar disorder, and anxiety disorder, the record showed a PASRR Level II completed on 7/13/21, but the Annual MDS dated [DATE] documented at A1500 that the resident did not have a PASRR Level II. On 3/18/25, the DON stated that this Annual MDS assessment was not accurately completed and that A1500 should have been marked "Yes" to reflect the existing PASRR Level II. These inaccuracies in MDS coding for physical restraints and PASRR Level II status were identified through record review and confirmed by staff interview with the DON.
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