Inaccurate MDS Coding for IV Therapy, Insulin Use, and Behaviors
Penalty
Summary
The deficiency involves inaccurate coding of Minimum Data Set (MDS) assessments for multiple residents, resulting in failure to capture IV therapy, IV antibiotic use, insulin use, and behavioral symptoms. One resident was admitted with pneumonia and meningitis requiring IV access and IV antibiotic medications. Documentation showed the resident arrived with IV access in the right antecubital fossa, had physician orders for IV ceftriaxone every 12 hours, and received IV antibiotics and saline flushes over several days, with notes indicating use of a midline catheter. However, the discharge return not anticipated MDS assessment did not indicate the presence of a midline IV access or that IV antibiotics were received upon admission, during the stay, or at discharge. The MDS Nurse later acknowledged that IV access and IV antibiotic use were not marked and that this was an error. Another resident with Type 2 diabetes mellitus with hyperglycemia had a physician order for Tirzepatide to be administered subcutaneously once weekly, and the Medication Administration Record confirmed that this medication was given as ordered. There was no indication on the MAR that the resident received any insulin injections. Despite this, the admission MDS assessment coded that the resident had received one insulin injection. The MDS Nurse who completed the assessment stated she coded one insulin injection because she believed Tirzepatide was considered insulin and later realized this was incorrect, confirming that the MDS had been inaccurately coded. A third resident admitted with an anxiety disorder exhibited multiple documented behaviors during the MDS assessment look-back period, including grabbing others, hitting, physical aggression, agitation, anxiousness, exit seeking, yelling, throwing medication, refusing care, restlessness, and wandering. These behaviors were recorded on behavior monitoring reports and in progress notes by nursing staff and the Administrator. Despite this documentation, the admission MDS with an Assessment Reference Date within this period coded the resident as having no behaviors, although it did indicate severe cognitive impairment and receipt of antianxiety medication. The Social Work Assistant responsible for coding behaviors on the MDS stated she did not observe these behaviors during the assessment period, was not aware she needed to review the electronic medical record for documented behaviors, and was unaware that such behaviors had been documented, leading to the omission of behaviors on the MDS.
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