F0641

D

Inaccurate MDS Coding for Behavioral Symptoms and Mood

San Antonio, Texas Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) assessments accurately reflected the behavioral and mood status of two residents with dementia and psychiatric diagnoses. For one resident with Alzheimer’s disease, anxiety, depression, and spastic hemiplegia, the admission MDS documented severely impaired cognition, total dependence in self-care and mobility, and no physical or verbal behavioral symptoms directed toward others. Despite this, multiple nursing progress notes around the time of admission described the resident as verbally and physically aggressive toward staff during ADL care, including striking at a CNA, attempting to hit, push, and grab staff, and being combative and refusing medications, weights, and care. An incident report and nursing note also documented that this resident slapped her roommate in the face, leading to separation of the residents and placement of the aggressive resident near the nurse’s station. These documented behaviors were not reflected in the admission MDS, and the triggered care areas did not include psychosocial well-being or behavioral symptoms directed toward others.

The same resident’s care plan, initiated and revised shortly after admission, addressed cognitive impairment, impaired communication due to a language barrier, and potential adverse effects of antidepressant medications, but there was no documented review or revision of the care plan following the admission MDS assessment that had triggered care areas such as cognitive loss/dementia, communication, falls, and psychotropic drug use. Staff interviews corroborated that this resident was verbally and physically aggressive when she first arrived, often swinging at staff during care, and that she could be more agitated in the afternoons. CNAs, a medical assistant, and physical therapy staff all described a pattern of aggression and the need for de-escalation techniques and family involvement, yet these ongoing behaviors and related interventions were not captured in the MDS assessment or reflected in updated care planning tied to that assessment.

For a second resident with Alzheimer’s disease, major depressive disorder, recurrent suicidal ideation, repeated falls, and a cognitive communication deficit, the quarterly and significant change MDS assessments documented severely impaired cognition, some need for help with self-care, independent mobility, and no physical or verbal behavioral symptoms directed toward others. However, facility records showed that this resident had a history of physically and verbally aggressive behavior, including cursing, yelling, throwing items, and a documented incident where she punched a roommate in the jaw during a dispute over a privacy curtain. An incident report described this resident as verbally and physically aggressive toward her roommate, resulting in a room change and notification of leadership and the physician. The resident’s care plan included a problem for physically abusive behavior with interventions such as room change, behavior documentation, and obtaining antianxiety medication, but the MDS did not reflect these behaviors.

Additionally, this second resident experienced an episode of suicidal ideation when she reportedly stated she was going to kill herself while walking down the hallway. A nurse documented locating and assessing the resident, who then denied making the statement and denied suicidal ideation, intent, or plan. A psychiatric mental health nurse practitioner note on the same date recorded that the resident had been placed on 1:1 observation after voicing a desire to kill herself, that she later denied active or passive suicidal ideation, and that her sertraline dose was increased. Despite this episode and the implementation of psychotropic medication changes, the subsequent quarterly MDS did not accurately reflect Section D – Mood in relation to suicidal ideation, and there was no documented review or revision of the care plan addressing psychosocial well-being following this incident. Interviews with the regional nurse, MDS coordinator, ADON, senior director, and former administrator confirmed awareness of the resident-to-resident incidents and suicidal ideation, acknowledged that IDT meetings occurred and interventions were implemented, and attributed the lack of MDS updates to staff turnover, documentation errors, and failure to revise assessments as required by facility policy and the RAI Manual.

The facility’s own MDS 3.0 Completion policy stated that residents are to be comprehensively assessed to identify care needs and develop an interdisciplinary care plan, and that a Significant Change in Status Assessment must be completed within 14 days of identifying a qualifying status change. Leadership interviews indicated that changes in cognition, ADLs, behavior, and psych interventions or medications could constitute a significant change, yet the behavioral aggression and suicidal ideation episodes for these two residents were not incorporated into updated MDS assessments. As a result, the assessments did not accurately reflect the residents’ physical and verbal behavioral symptoms directed toward others or mood status, despite clear documentation of these issues in progress notes, incident reports, psychiatric evaluations, and staff interviews.