Incorrect MDS Coding for Catheter Status: A resident’s MDS was coded as if the resident used a catheter and had urinary leakage, but the TAR had no documentation or physician orders supporting catheter use. The resident stated no catheter had been used since admission, and the MDS Coordinator acknowledged the assessment was coded incorrectly and that the resident did not currently have a catheter.
MDS assessments for 5 of 5 sampled residents incorrectly coded bed rails as physical restraints in Section P. Care plans either did not mention restraints or identified turn rails for bed mobility and transfers, while the MDS Coordinator stated she marked yes whenever side rails were present and that about 15 residents had been coded this way. The DON stated the facility had no residents using restraints or alarms and did not have a policy for MDS accuracy.
Inaccurate MDS coding affected two residents. One resident with dementia was coded as receiving an antipsychotic even though the EMAR showed Donepezil, not an antipsychotic, and the ADON/MDS Coordinator said she believed dementia drugs were classified as antipsychotics. Another resident was also coded for antipsychotic use without EMAR support, and the quarterly MDS failed to document oxygen use despite an active oxygen order and ETAR documentation showing it was provided.
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.
MDS assessments failed to accurately code PASRR status for two residents in Section A. One resident had a PASRR Level II approval with Specialized Services, and another had a PASRR Level I positive screen with MH disability and ID; however, both MDSs left A1500 coded as no and A1510 blank. The MDS Coordinator acknowledged the coding errors during interview and stated the assessments should have reflected the PASRR findings.
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.
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