F0641

E

Inaccurate MDS Coding for Hearing, Oxygen Use, and Functional Status

Rio Rancho, New Mexico Survey Completed on 02-11-2026

Penalty

Fine: $17,215

Summary

The deficiency involves inaccurate completion of the Minimum Data Set (MDS) for two residents, resulting in assessments that did not reflect their actual hearing status, oxygen (O2) use, and functional abilities. For one resident with metabolic encephalopathy, influenza A, acute respiratory failure with hypoxia, and acute pulmonary edema, surveyors observed that he repeatedly responded "huh" during attempted interviews and interactions, indicating difficulty hearing. Despite this, his MDS documented no difficulty in normal conversation or social interaction, no hearing aid in use, and an ability to understand others. The MDS also indicated receipt of speech-language pathology and audiology services, while physician orders and notes contained no documentation of hearing aids, audiology assessments, or hearing services, and physician notes described his speech as clear and that he was able to understand and be understood. An LPN stated the resident was hard of hearing and did not have hearing aids at the facility, and the DON later acknowledged she was unaware of any hearing issues and that the MDS hearing section was not accurate.

The same resident’s MDS was also inaccurate regarding O2 use. Physician progress notes over January documented fluctuating O2 saturations, continued O2 supplementation, and use of O2 via nasal cannula at 2 LPM, with later notes indicating the resident was on room air. Nursing notes during this period alternately documented no O2 in use, room air, and O2 via nasal cannula. A physician order dated early February called for a room air trial to determine ongoing O2 need, and on observation the resident was seen on room air with an oxygen concentrator at the bedside that was off and without tubing attached. Despite this history of O2 use and changes, the resident’s MDS contained no documentation regarding O2 use. The DON stated it was her expectation that O2 use be documented in the MDS and confirmed the MDS was not accurate regarding O2 use.

For a second resident with Parkinson’s disease, dysphagia, and scoliosis, nursing progress notes over several months documented that she was bedbound and dependent on all activities of daily living, with multiple entries describing her as bedbound and at baseline in that status. However, two MDS assessments during this period coded Section GG (Functional Abilities) to indicate that a wheelchair (manual or electric) was the mobility device normally used in the last seven days. Observations by surveyors found the resident to be bedbound, and the DON stated that the resident’s functional decline from wheelchair use to being bedbound should have been considered a change in condition, but she could not determine when the change occurred. The DON further stated that documentation showed the resident had been bedbound since 2023, that she did not recall the resident using a wheelchair, and that the MDS assessments were documented incorrectly because the resident could not use a wheelchair and required bedbound care. A significant change MDS was not completed despite this documented functional decline.