A facility failed to accurately complete MDS assessments for 3 residents. One resident’s MDS incorrectly documented tracheostomy care despite no physician order, no progress note support, no care plan entry, and the resident stating she never had a tracheostomy. Two other residents’ MDSs incorrectly identified anticoagulant therapy; one resident was on aspirin and the other had no physician order for a blood thinner, while the DON stated the entries were made in error.
Inaccurate MDS Medication Coding: The facility failed to accurately code medication use on the MDS for two residents. One resident with CAD, CVA, and non-Alzheimer's dementia was incorrectly documented as receiving diuretics despite no active order or history of use, and another resident with HF, DM, obesity, and respiratory failure was incorrectly documented as receiving insulin despite no active order and use of Ozempic instead. The DON confirmed both entries were incorrect.
Inaccurate MDS Coding for PASRR Status: A resident’s MDS incorrectly stated the resident was not considered by the state PASRR Level II process to have serious mental illness or intellectual disability, even though the resident’s PASRR document showed a Level II outcome with specialized services approved. The resident’s care plan included PASRR goals and interventions, and the MDS Coordinator acknowledged the assessment was coded inaccurately and should have reflected Level II status. The DON stated the MDS Coordinator must follow the RAI manual and facility policies.
Inaccurate MDS Coding for Resident Mobility: A resident’s MDS coded partial/moderate assistance for transfers and ambulation despite the care plan, Kardex, observations, and multiple CNA/CMA interviews showing the resident was independent with transfers and walking using a 4WW. The MDS also recorded severe cognitive impairment with a BIMS score of 3/15, and facility leadership stated MDS coding was expected to accurately reflect residents’ levels of care and assistance.
The facility failed to ensure MDS assessments accurately reflected resident condition for two residents. One resident’s MDS did not show the Level II PASRR outcome despite documentation that the resident needed NF services and specialized behavioral health/developmental services. Another resident had a PEG tube, tube feeding orders, and observed enteral feeding, but the MDS did not document the feeding tube even though the RN signed that the assessment was accurate.
The facility failed to accurately code MDS assessments for psychotropic medication-related diagnoses and restraint use. Four residents had prescribed antianxiety and/or antidepressant medications tied to diagnoses that were not entered on the MDS, despite physician orders and charted conditions. Two residents had daily use of restraints documented in the care plan, MAR/TAR, and staff interviews, but the MDS showed no restraints or alarms. The DON stated the devices were physical restraints and should have been reflected on the assessments.
Failure to complete a discharge MDS assessment for a resident who discharged home. Record review showed the resident had an Entry MDS and an admission MDS completed, but no discharge MDS was completed after the resident left the facility. The Administrator and Nurse Consultant stated staff follow the RAI manual.
MDS and care plan PASRR documentation was not accurately completed for two residents with Level II PASRR status. Both residents had psychiatric diagnoses and notices showing approval for specialized services, but A1500 was marked no and A1510 was left blank, and the care plans lacked PASRR documentation. Staff interviews confirmed the residents were Level II PASRR residents and that the PASRR entries were incorrect.
MDS assessments were coded inaccurately for two residents. One resident with neurogenic bladder, MS, and depression had an indwelling Foley catheter documented in the clinical record and physician orders, but the MDS showed no appliance. Another resident’s MDS listed depression but did not code antidepressant use even though the MAR showed trazodone and mirtazapine; the MDS Coordinator acknowledged the miscoding and stated antidepressants should be coded by pharmacological class.
A resident’s initial BIMS was not completed as part of the MDS assessment. The record showed the resident was not assessed, and the Administrator stated the omission occurred because a PRN traveling MDS person worked remotely and a miscommunication kept the need for the assessment from being conveyed to the facility team. A later PRN BIMS showed moderately impaired cognition.
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