Inaccurate MDS Coding for Medications and Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to ensure that MDS assessments accurately reflected residents’ clinical status for three residents. For one resident with dementia and depression who was receiving an antipsychotic (Rexulti) daily, a psychiatry consult documented that a gradual dose reduction (GDR) should not be attempted because the benefits outweighed the risks. However, the resident’s Quarterly MDS for the specified assessment reference date did not indicate in Section N, question N0450, that the physician had documented a GDR as clinically contraindicated. For another resident with bipolar disorder, anxiety disorder, depression, and dementia who was receiving antipsychotic, antidepressant, anticonvulsant, and diuretic medications, the Annual MDS for the specified assessment reference date documented only antibiotic and insulin use in Section N, despite the Medication Administration Record showing administration of the other medications during the reference period. In addition, this same resident had a psychiatry consult stating that no GDR of the antipsychotic should be attempted because benefits outweighed risks, but the Quarterly MDS did not indicate that the physician had documented a GDR as clinically contraindicated in Section N0450. Another resident with hypertension and obesity was readmitted after a hospital stay and was noted in the clinical record to have Stage 2, Stage 3, and Stage 4 pressure ulcers present upon admission. The resident’s Quarterly MDS with one assessment reference date documented in Section M that the Stage 2 and Stage 3 pressure ulcers were present upon admission, but coded the Stage 4 pressure ulcer as not present upon admission. A subsequent Quarterly MDS with a later assessment reference date documented only that a Stage 4 pressure ulcer was not present upon admission. During interviews, the Regional Director of Clinical Services and the DON confirmed that these MDS assessments for all three residents were not coded accurately and that the MDS should be an accurate reflection of each resident’s status.
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