Inaccurate MDS Coding for Wounds, IV Access, and Medications
Penalty
Summary
The facility failed to ensure accurate completion of MDS assessments for three residents by not correctly coding existing conditions and treatments documented in their records. One resident with dementia and behaviors had a wound provider note identifying a stage 4 pressure ulcer to the sacrum, a stage 3 pressure ulcer to the left buttock, and an unstageable deep tissue injury to the right heel. However, the quarterly MDS assessment coded only one stage 3 pressure ulcer and one unstageable deep tissue injury, omitting the documented stage 4 pressure ulcer. The MDS nurse confirmed that the stage 4 pressure ulcer was present at the time of the assessment and acknowledged she had overlooked it despite having the wound provider documentation available. Another resident admitted with osteomyelitis of the right ankle and foot had a physician order for IV vancomycin via a PICC line and a care plan addressing IV medication via PICC with associated risks. The admission MDS assessment coded IV medication use but did not code IV access, and the MDS nurse later acknowledged that the PICC line should have been coded as IV access and that it was inadvertently overlooked. A third resident with coronary artery disease and a history of cerebral infarction had a standing order and ongoing administration of clopidogrel, an antiplatelet medication, as documented in the MAR. The quarterly MDS assessment for this resident was coded as receiving an anticoagulant, and the nurse being trained on MDS completion confirmed this was an error in coding. In each case, the Administrator stated that the responsible MDS staff should have completed the assessments accurately based on the available information.
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