Inaccurate MDS Coding for Resident Fall: A resident with dementia and behavioral disturbances had a quarterly MDS that did not include a documented unwitnessed fall with bruising and a laceration, even though the event occurred during the assessment period. The MDSC confirmed the fall should have been included, and the DON stated the MDS was to be accurate.
A resident with dementia, agitation, and Parkinson's disease had a Discharge MDS that documented no behavioral symptoms and intact cognitive status, even though the record showed severe aggression, including choking staff, attempting to strike staff with a cup, barricading a door, and requiring police, EMS, and NP involvement before transfer to the hospital. The SSD, SSA, DON, and Administrator confirmed the MDS Section E was coded incorrectly and should have reflected the resident's current condition.
Incorrect MDS Coding and Missing Physician Orders for Monitoring Device: A resident with dementia, mood disorder, and generalized anxiety disorder was observed wearing a monitoring device bracelet on her ankle. The MDS Coordinator and DON confirmed the device was in use, but the Quarterly MDS Section P was coded as no wandering or elopement alarm. The resident’s care plan documented wandering/risk for elopement and use of a monitoring device, while the BIMS score showed severe cognitive impairment.
A resident’s admission MDS was inaccurate because it did not include a PTSD diagnosis, even though the resident confirmed the diagnosis and the psychiatrist had ordered Mirtazapine for PTSD and depression. The MDSC said she reviewed hospital records, consulted the NP, and checked physician orders, but the facility was not notified of the new PTSD diagnosis.
Inaccurate MDS Coding for Side Rail Use: A resident with Alzheimer's disease and cognitive communication deficit had a quarterly MDS that incorrectly coded daily side rail use and restraint use. Observations showed the resident in bed without side rails or restraints, and both an LPN and the MDSC confirmed the resident had never used bedside rails or any physical restraints. The Administrator also acknowledged the MDS was inaccurate.
MDS Incorrectly Coded Discontinued Antipsychotic Medication: A resident with Alzheimer's disease and dementia with behavioral disturbance had quetiapine discontinued, but the annual MDS still indicated antipsychotic use. The MDS Coordinator confirmed the med was outside the 7-day look-back period and should not have been coded, while the care plan and MAR reflected the discontinuation.
Inaccurate MDS coding for significant weight loss. A resident with encephalopathy, pneumonia, severe sepsis with septic shock, and oropharyngeal cancer had a significant unplanned weight decline, but the quarterly MDS coded weight loss as a physician-prescribed weight-loss regimen. Dietary notes documented trending weight loss and variable intake, and the MDS Coordinator said the coding was based on diuretic use even though the medication had been prescribed long before. The DHS confirmed the coding was inaccurate and that no care plan revisions had been made to address the weight trend.
A resident with protein calorie malnutrition and a terminal prognosis was admitted on hospice with corresponding physician orders and a care plan, but hospice services were not coded on either the admission or quarterly MDS assessments. The MDS Coordinator and two MDS LPNs confirmed that, despite the resident receiving hospice care, Section O of both MDS assessments incorrectly indicated the resident was not on hospice, which the Administrator and DON acknowledged resulted in inaccurate MDS data.
An inaccurate MDS assessment failed to code a resident’s ordered CPAP use in Section O, even though the resident had diagnoses including OSA, COPD, asthma, and acute respiratory failure with hypercapnia. The resident was observed on supplemental O2 and reported using O2 daily and attempting to wear CPAP at night; the RN Case Mix Director and Administrator confirmed the respiratory treatments had not been coded on the MDS.
Surveyors found that MDS assessments were not accurately completed for two residents. One resident with multiple medical conditions, including epilepsy and vascular dementia, had a quarterly MDS that documented no falls, even though facility incident records and staff interviews confirmed an unwitnessed fall that led to hospital transfer. Another resident with peripheral vascular disease had an MDS indicating daily bed rail use, while observations over several days, the resident’s own statements, the care plan, and physician orders all showed that no bed rails were present or ordered. The MDS Coordinator and unit leadership acknowledged that the MDS coding for both residents was incorrect.
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