A resident’s MDS incorrectly coded restraint use even though staff and records showed no restraints and the facility was restraint free. Another resident who spoke Swahili was coded as rarely/never understood, and the BIMS and mood interviews were not completed in the resident’s preferred language. A third resident’s discharge and annual MDS failed to identify an unstageable pressure ulcer on the left hand despite skin assessments, treatment records, and hospital documentation confirming the wound.
The facility failed to ensure accurate MDS coding for three residents. One resident with dementia and cardiac history was incorrectly coded for a hypnotic medication even though the MAR supported Ativan use, another resident with dementia and brain dysfunction had a documented fall that was omitted from the MDS, and a third resident with dysphagia and gastrostomy status had g-tube feeding and medication administration documented in the record but was coded as not having a feeding tube.
A resident with cataracts and a prescription for eyeglasses was inaccurately coded on the MDS assessment as not using corrective lenses, despite optometry records, resident statements, and direct observation confirming eyeglass use. The error was acknowledged by the MDS nurse, who attributed it to a float staff member completing the assessment.
The facility failed to ensure accurate MDS assessments for two residents, with one resident incorrectly documented as using a restraint and another inaccurately recorded as receiving insulin when only a non-insulin injectable was administered. These inaccuracies were identified through interviews, record reviews, and direct observation.
Two residents did not have their MDS assessments accurately coded: one experienced a significant weight gain that was not reflected in the MDS, and another who used tobacco was not coded for tobacco use, despite documentation and observation confirming these conditions.
The facility failed to accurately complete MDS assessments for three residents, including not coding diuretic use for a resident with heart failure, misclassifying antiplatelet medications as anticoagulants for another, omitting tobacco use for a resident who smoked, and not documenting a therapeutic diet for a resident on dialysis, despite clear evidence in medical records and staff interviews.
Surveyors identified that several residents' MDS assessments were inaccurately coded, failing to reflect actual clinical treatments and medications such as IV access, antidepressant and antipsychotic use, anti-anxiety medication, and dialysis. These discrepancies were confirmed through record review and staff interviews, with the MDS Nurse acknowledging the errors.
Surveyors identified that several MDS assessments were inaccurately coded, including cases where a resident receiving daily insulin was not coded for insulin administration, a pressure ulcer present on admission was not documented as such, and a resident on continuous oxygen therapy was not coded for oxygen use. Additional errors included incorrect documentation of anticoagulant use and discharge location, with staff interviews confirming these discrepancies between clinical records and MDS entries.
The facility did not accurately complete MDS assessments for two residents. One resident receiving hospice care was not coded as such on the MDS, despite having a physician's order and being admitted to hospice. Another resident transferred to the hospital for an acute health change was incorrectly coded as 'discharge return not anticipated,' even though staff expected the resident to return. These inaccuracies were confirmed by the MDS nurse.
Surveyors identified deficiencies in the completion of MDS assessments for three residents, including inaccurate coding of vision status for a resident with cataracts and macular degeneration, and incorrect documentation of transfer assistance for two residents who had not been out of bed for months. Staff interviews confirmed that CNA documentation was based on hypothetical rather than actual care provided, leading to errors in the MDS.
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