Inaccurate MDS Coding for Catheter Use and Medication Regimen
Penalty
Summary
The deficiency involves inaccurate coding of MDS assessments for two residents, resulting in failure to ensure accurate resident assessments. For one resident with a diagnosis including flaccid neuropathic (underactive) bladder, physician orders initially directed use of an indwelling urinary catheter with catheter care every shift, and later discontinued the indwelling catheter in favor of intermittent catheterization as needed. Nursing documentation on the MAR showed catheter care every shift from early July through mid-August, consistent with the indwelling catheter order until it was discontinued. However, the quarterly MDS assessments completed after the resident had transitioned to intermittent catheterization continued to code the resident as having an indwelling urinary catheter. The MDS coordinator who completed these assessments acknowledged during interview that the resident no longer had an indwelling catheter at the time of the assessments and that the MDS should have been coded to reflect intermittent catheter use instead. For another resident admitted with mood disorder, major depressive disorder, pain, and later localized edema, physician orders and the MAR showed daily administration of Risperdal for mood disorder, Duloxetine for major depressive disorder, and Furosemide/Lasix for localized edema, with no orders or administration of opioid medications. A quarterly MDS assessment for this resident, completed by the same MDS nurse, coded the resident as receiving medications from the antipsychotic, antidepressant, diuretic, and opioid drug classes, and did not document indications for use for any of these medications. During interview, the MDS nurse stated that omitting the indications for use was an oversight, confirmed that the resident had diagnoses supporting the use of antipsychotic, antidepressant, and diuretic medications, and acknowledged that the resident did not receive any opioid medications and that coding opioid use was a mistake.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.