Inaccurate MDS Coding for Behavioral Symptoms and Mood
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with severe cognitive impairment, Type I DM, and Alzheimer’s disease had an MDS that incorrectly identified 2 DTIs and pressure-reducing devices despite EMR and wound documentation showing both heel wounds had healed. Staff confirmed the wounds were healed and stated the ongoing wound care was preventative, and the RN who completed the MDS acknowledged the DTIs were entered in error.
Inaccurate Dental Assessment Documentation: A resident’s annual and quarterly MDS nursing assessments did not identify oral/dental concerns, despite a dental note documenting multiple missing and fractured teeth and an observation showing obvious missing teeth and a broken tooth. The resident had diabetes and chronic pain syndrome, and staff stated nursing assessments were used to code the MDS and should accurately reflect the resident’s status.
A resident's MDS was coded incorrectly in Section N for high-risk drug classes, showing antipsychotic use even though the MAR showed no antipsychotic medications during the look-back period. The DON stated the resident had not taken an antipsychotic during the stay, and the Corporate MDS Coordinator confirmed the MDS was incorrect and that "yes" had been selected in error for lamotrigine.
Inaccurate MDS coding affected three residents. One resident’s quarterly MDS omitted a musculoskeletal fracture, behavioral symptoms, and active diagnoses despite records showing dementia, depression, psychosis, and physical aggression. Another resident’s MDS failed to code falls, fall frequency, and falls with and without injury despite severe cognitive impairment and dependence. A third resident’s MDS omitted falls and a musculoskeletal fracture despite multiple fracture diagnoses, hospital discharge after a fall, and incident reports showing unwitnessed falls with injuries; the MDS nurse acknowledged the assessments were inaccurate.
A resident’s MDS was inaccurate because suctioning was not checked in Section O0110 D1 even though the resident had a tracheostomy and suction trach care was ordered and documented in the MAR. The resident’s care plan called for suction trach and oral care every shift and as needed, and the RNAC confirmed the omission on the MDS.
Inaccurate MDS coding led to incomplete BIMS and mood interviews for seven residents. Several residents were documented as rarely/never understood, which prevented completion of the BIMS and mood interviews, even though surveyor interviews and observations showed they had clear speech and could answer questions about their names, birthdays, food, care, and staff treatment. The RN assessment nurse confirmed that residents who are at least somewhat understood should not be coded as rarely/never understood, and the NHA and DON acknowledged the assessments were not fully completed.
MDS inaccurately reflected healed heel wounds
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected R77’s status. R77’s quarterly MDS identified severe cognitive impairment, diagnoses of Type I Diabetes and Alzheimer’s disease, and indicated that she had 2 deep tissue injuries (DTIs) and used a pressure reducing device for her bed and chair. However, the electronic medical record showed that R77’s DTIs were healed on 6/9/26, and weekly wound documentation also identified that the DTIs on both heels had healed. The physician order dated 6/9/26 to 7/7/26 directed wound care for the left heel unstageable DTI, including daily skin prep, but staff stated this ongoing care was a preventative measure after the wounds had healed. During interviews, RN-E confirmed the heel areas had healed and the weekly wound notes reflected that status. RN-F, who completed the MDS, stated she was unsure why 2 DTIs were entered, later said she had entered them because the resident had been receiving wound care until 7/7/26, and then acknowledged the DTIs should not have been identified on the MDS and were entered in error. The DON stated MDS accuracy affected the resident care plan and should reflect the resident’s current needs.
Inaccurate Dental Assessment Documentation
Penalty
Summary
The facility failed to ensure resident assessments were accurate for one resident reviewed for dental care. The resident’s annual MDS indicated the resident was cognitively intact, needed setup or clean-up assistance with oral hygiene, and did not identify any oral or dental concerns; the quarterly MDS nursing assessment also indicated that obvious or likely cavity or broken natural teeth were not checked. The resident’s diagnoses included diabetes and chronic pain syndrome, and the care plan noted the resident had her own teeth, some with crowns. However, the resident’s HealthDrive dental note documented ten missing teeth and three fractured teeth, and another note indicated the resident was scheduled for a dental appointment but declined because she did not feel well. The EMR lacked evidence of any other dental appointments. During observation, the resident had several missing teeth, including obvious missing teeth on the upper front gumline and several scattered along the lower gumline, and stated she had a lot of missing teeth and at least one broken tooth on the upper and back right side. Staff interviews confirmed nursing assessments were expected to be completed face to face and used to code the MDS, and the DON stated nursing assessments should accurately reflect the resident’s status.
Incomplete and Inaccurate MDS Assessment
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were complete and accurate for Resident #11. The MDS titled Significant Change dated 05/20/26 documented Section N, High-Risk Drug Classes, antipsychotics as "yes," but review of the resident's Medication Administration Record for May 2026 showed no antipsychotic medications were administered during the look-back period for the MDS. During interview, the DON stated Resident #11 had not taken an antipsychotic medication during her stay at the facility. The Corporate MDS Coordinator stated the MDS was incorrect and that antipsychotic medication had been clicked "yes" instead of "no" for lamotrigine.
Inaccurate MDS Assessments for Fractures, Falls, and Behavioral Symptoms
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected resident status for three residents whose records were reviewed. For Resident #3, the quarterly MDS was completed with a BIMS score of 00, but it did not code a musculoskeletal other fracture and did not indicate any behavioral symptoms, including physical behavioral symptoms toward others. The record also showed active diagnoses of Alzheimer’s disease, non-Alzheimer’s dementia, anxiety disorder, depression, and psychotic disorder, while the care plan documented potential physical aggression, yelling, kicking, and hitting/pinching staff, as well as an alteration in musculoskeletal status related to a pubis fracture. For Resident #40, the quarterly MDS reflected a BIMS score of 00 and documented severe cognitive impairment, impaired range of motion in both upper and lower extremities, and dependence on staff. However, the assessment did not code falls, the frequency of falls, or falls with and without injury. The resident’s care plan documented impaired cognitive function related to dementia and little or no activity involvement related to physical limitations and cognitive impairment. For Resident #56, the quarterly MDS reflected a BIMS score of 05 and documented severe cognitive impairment with dependent to substantial/maximal assistance for functional abilities, but it did not code falls or musculoskeletal other fracture. The record showed multiple diagnoses including vertebral compression fracture, osteoporosis with pathological fracture, fracture of the right humerus, fracture of the right femur, altered mental status, and cognitive communication deficit. The record also included hospital discharge information for splenic laceration and multiple rib fractures after a fall, along with incident reports documenting unwitnessed falls with injuries such as skin tears and abrasions. During interview, the MDS Nurse stated the assessments were inaccurate for these residents and that she was responsible for their accuracy.
MDS Did Not Accurately Reflect Suctioning
Penalty
Summary
Resident R164’s assessment was inaccurate because Section O0110 D1, suctioning, was not indicated on the MDS even though the resident had a tracheostomy and suctioning was being performed. The resident’s record showed diagnoses of diabetes, heart failure, and stroke, and the admission record confirmed the resident was admitted to the facility. The RAI User’s Manual stated that suctioning performed while a resident is in the facility and within the last 14 days must be checked in Section O0110 D1. The resident had a physician order dated 7/20/26 to check that the trach mask and oxygen were in place and to check the need for suctioning, trach care, and oral care four times a day. The care plan directed suction trach and oral care every shift and every two hours as needed. The MAR from 7/20/26 through 7/26/26 showed suction tracheostomy was performed on 7/22/26, 7/23/26, 7/24/26, 7/25/26, and 7/26/26. During interview on 8/5/26, the RNAC confirmed the MDS for Resident R164 did not indicate suctioning in Section O0110 D1.
Inaccurate MDS coding led to incomplete BIMS and mood interviews
Penalty
Summary
The facility failed to ensure that comprehensive MDS assessments were accurate and fully completed for seven residents. The cited issue involved Section B coding for hearing, speech, and vision, where residents were documented as rarely or never understood, which then led to Section C BIMS interviews and Section D mood interviews not being completed. The RAI User’s Manual instructions cited in the report stated that if a resident is at least sometimes understood, the BIMS and mood interviews should be conducted. For Resident R19, the MDS listed kidney disease, Alzheimer’s disease, and malnutrition, and coded the resident as rarely/never understood in Section B, with BIMS and mood interviews not completed. During surveyor interview, however, R19 had clear speech, provided her name and birth month, and answered questions about meals; the birth month matched the clinical record. Resident R21’s MDS listed diabetes, osteoporosis, and dementia and also coded the resident as rarely/never understood, with no BIMS or mood interview completed. During interview, R21 was confused but had clear speech and was able to be understood. Resident R58’s MDS listed kidney disease, diabetes, and dementia and similarly omitted the BIMS and mood interviews after coding the resident as rarely/never understood; during interview, R58 had clear speech, gave her name and birthday, and answered questions about food, staff treatment, and care, with the birthday confirmed by the record. Resident R22’s MDS listed heart failure, diabetes, and dementia and also coded the resident as rarely/never understood, with no BIMS or mood interview completed; during interview, R22 provided his preferred name, had clear speech, answered questions about food and care, and stated his birthdate correctly. Resident R93’s MDS listed osteoporosis, malnutrition, and dementia and coded the resident as rarely/never understood, with BIMS and mood interviews not completed. During interview, R93 had clear speech, provided her full name, answered questions about food, staff respect, and ADL care, and was able to discuss assistance in and out of bed. Resident R51’s MDS listed anxiety, depression, and dementia and also coded the resident as rarely/never understood, with no BIMS or mood interview completed; during observation, R51 had clear speech, held a simple conversation, and answered questions about the prior day’s food activity. Resident R118’s MDS listed kidney disease, malnutrition, and Alzheimer’s disease and likewise coded the resident as rarely/never understood, with no BIMS or mood interview completed; during observation, R118 had clear speech, answered questions appropriately, and shook her head when asked if she had concerns about her care. The RN assessment nurse confirmed that if a resident is at least somewhat understood, the resident should not be coded as rarely/never understood and the BIMS and PHQ-9 assessments should be attempted, and the NHA and DON confirmed the facility failed to ensure the MDS assessments were accurate and fully completed for seven residents.
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