A resident’s admission MDS was coded incorrectly in Section A1500 as not having a PASRR Level II, even though the EMR contained a PASRR Level II screening. The resident had PTSD, TBI, anxiety, and major depressive disorder, and the CEO and MDS Nurse confirmed the MDS should have been coded yes.
A resident admitted for end-of-life care with heart failure and chronic kidney disease had a hospice physician’s certification of terminal illness in the record and was admitted with hospice services. However, the Admission MDS assessment inaccurately coded the hospice services item in Section O as not receiving hospice. During interview, the Administrator acknowledged that the resident was on hospice at admission and that the MDS assessment was not accurate.
The facility failed to ensure accurate MDS assessments when two residents were incorrectly coded as having daily physical restraints in section P0100, despite observations showing no restraints in their beds or wheelchairs. One resident with epilepsy and dementia was seen in a wheelchair without restraints, while another resident with diabetes and an above-the-knee amputation was observed in bed using only a trapeze bar for repositioning. The DON and MDS coordinator later acknowledged that the restraint coding on both MDS assessments was incorrect.
Two residents’ MDS assessments were inaccurately completed, leading to incorrect transmission of assessment data. For one resident with anxiety, depression, and personal care needs, a Quarterly MDS incorrectly indicated the use of physical restraints in bed or chair less than daily. For another resident with hemiplegia/hemiparesis, COPD, ESRD, depression, bipolar disorder, and anxiety disorder, the record showed a completed PASRR Level II, but the Annual MDS incorrectly documented that no PASRR Level II existed. These errors were identified through record review and confirmed by the DON.
Surveyors found that MDS assessments were inaccurately coded for two residents. One resident who used CPAP and had never required an invasive mechanical ventilator was incorrectly coded on the Quarterly MDS as receiving invasive mechanical ventilation. Another resident with documented bipolar disorder, depression, and anxiety and an Abbreviated Level 2 PASRR identifying severe mental illness was coded on the Admission MDS as not being considered by the state Level 2 PASRR process to have a serious mental illness or related condition. The MDS Coordinator acknowledged both errors and lack of awareness regarding the need to align PASRR findings with MDS coding.
Two residents had inaccurate MDS assessments when key clinical information was miscoded. One resident with serious mental illness had a Significant Change MDS coded as not having a Level II PASRR, even though a Level II PASRR was present in the medical record. Another resident with ESRD on dialysis had a Quarterly MDS coded to indicate an indwelling Foley catheter, but observation confirmed no catheter was in place, and the MDS coordinator acknowledged this was an error.
A resident with multiple medical conditions had conflicting MDS assessments regarding mobility, with the admission assessment showing no impairment and the quarterly assessment incorrectly documenting impairments. Observations confirmed the resident could move both arms, and the MDS nurse later acknowledged the quarterly assessment was coded in error.
A resident with hypertensive heart disease with heart failure and acute and chronic respiratory failure with hypoxia had a Quarterly MDS that stated oxygen therapy was not being received, even though the care plan indicated oxygen was ordered and the resident was observed receiving O2 via nasal cannula. The MDS Coordinator later stated the assessment should have been coded Yes for oxygen.
Three residents with documented serious mental illness or intellectual disability had inaccurate MDS assessments, as staff failed to correctly reflect PASRR findings in the MDS records. The MDS nurse acknowledged the errors after review and interview.
A resident with cerebral palsy and major depressive disorder had documented orders for hydroxyzine for anxiety and a diagnosis of severe dementia, but the MDS assessment failed to reflect the anxiety disorder, use of anti-anxiety medication, or dementia diagnosis. Staff confirmed these omissions in the MDS despite their presence in the medical record.
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