MDS coding was inaccurate for two residents. One resident with osteoarthritis and osteoporosis had OT documentation showing left hand and wrist contracture issues and a recommendation for a WHFO/palm guard, yet the MDSs did not code a functional ROM limitation for an upper extremity. Another resident with chronic respiratory failure, CKD, and atherosclerotic heart disease was coded as receiving an anticoagulant during the look-back period even though physician orders did not show an anticoagulant and the MDS nurse confirmed it was entered in error.
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.
MDS assessments not completed in residents’ preferred languages. The facility failed to complete BIMS interviews for one resident on multiple MDSs and for three other residents on singular MDSs using their preferred non-English languages. Records showed diagnoses including dementia, Alzheimer’s disease, anxiety, depression, and schizophrenia, with staff documenting that the residents were rarely or never understood and substituting staff cognitive assessments instead of attempting the BIMS in the residents’ languages. Interviews confirmed no interpreter was offered for one resident, and staff stated they did not attempt the assessments in the residents’ preferred languages.
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.
MDS assessments were inaccurate for two residents. One resident with significant psychiatric diagnoses had a BIMS score showing moderate cognitive impairment, but the PHQ-9 was not completed even though it should have been. Another resident with gait and balance problems had documented falls, including one with a head laceration requiring hospital evaluation and staples, and another fall with injury, but the MDS assessments did not code the falls correctly.
Inaccurate MDS coding affected multiple residents. The MDS did not reflect insulin or other hypoglycemic meds, hospice status, tobacco use, two documented falls, urinary continence status with an indwelling catheter, nutrition/hydration interventions for skin issues, or antipsychotic use. Records, MARs, physician orders, care plans, and direct observation showed the residents’ status differed from what was entered on the MDS, and an MDS nurse acknowledged the coding errors.
A resident with traumatic brain injury, abnormal posture, and a history of falls had an MDS that coded one fall with minor injury despite record review showing a fall with a subacute L1 compression fracture. Nursing notes, an incident report, and hospital records documented the fall and fracture, and the MDS Nurse stated the fracture should have been coded as a major injury per the RAI manual.
Inaccurate MDS Coding for Antipsychotic Medication Use: A resident with a psychotic disorder and intact cognition had MDS assessments that incorrectly indicated antipsychotic use even though the antipsychotic had been discontinued and the MAR showed no administration afterward. The MDS nurse acknowledged the assessments were coded inaccurately, and the DON stated MDS coding should follow RAI guidelines.
A resident with dementia and diabetes was found on the floor, bleeding and complaining of right arm pain, and was sent to the hospital after an unwitnessed fall. The hospital discharge summary documented a post-traumatic right humeral fracture, but the discharge MDS did not code the fall as a major injury. The MDS Nurse acknowledged the error, stating that bone fractures are major injuries, and the DON said MDS assessments should be coded according to the RAI manual.
Incomplete MDS Section F Interviews: Multiple residents had comprehensive MDS assessments that did not include required Resident or Staff Interviews for Preferences for Customary Routine and Activities. Several residents were cognitively intact or able to communicate, yet Section F was left blank, while others who could not participate also had no Staff Interview completed. An MDS nurse stated the facility had been without an Activities Director and that these interviews were not being completed as part of that role.
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