Inaccurate MDS Coding for Falls and Medication Use
Penalty
Summary
The deficiency involves inaccurate coding of Minimum Data Set (MDS) assessments for multiple residents in the areas of accidents and medications. One resident with a history of stroke and muscle weakness experienced a fall that caused a skin tear to his right arm. In the subsequent quarterly MDS, his cognition was coded as severely impaired and the fall section was coded as one fall with no injury since the previous assessment, despite documentation in the medical record that the fall resulted in a minor injury. The MDS Consultant who completed the assessment later confirmed that the fall should have been coded as one fall with a minor injury and described the incorrect coding as an oversight. Two additional residents had inaccuracies in the medication sections of their MDS assessments. One resident with neuromuscular bladder dysfunction and age-related cataracts received Macrobid orally once daily and Moxifloxacin eye drops every two hours during the lookback period, but the quarterly MDS did not code any antibiotic use, which the MDS Consultant later acknowledged should have been coded. Another resident with bipolar I disorder with psychotic features and schizophrenia had active orders and documented administration for an intramuscular antipsychotic injection and an oral anticonvulsant medication during the admission MDS lookback period. However, the admission MDS was coded as receiving zero injections and did not reflect anticonvulsant use. The Corporate MDS Consultant confirmed she did not accurately code the injections or the anticonvulsant, stating she overlooked the intramuscular aspect of the antipsychotic and the presence of the anticonvulsant when reviewing the MAR.
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