A resident with diabetes had quarterly MDS assessments that incorrectly coded insulin use despite current orders showing weekly semaglutide injections and no insulin orders. The resident stated she did not receive insulin, and an RN confirmed the MDS was coded incorrectly and needed modification. The DON stated the MDS should accurately reflect each resident’s status.
A resident’s quarterly MDS failed to code use of a non-invasive ventilatory device, even though a BiPAP machine was observed at bedside and the resident stated staff assisted with it at night. The chart also included orders for CPAP/BiPAP use for OSA, and the MDS coordinator confirmed the assessment was coded incorrectly.
A facility failed to accurately code MDS assessments for code alert device use for multiple residents identified as at risk for elopement and wandering. Although a wander guard log showed several residents had code alert devices, the MDS often stated the devices were not in use and did not reflect wandering behavior. Several care plans also lacked elopement or wandering interventions, and staff interviews confirmed the MDS should reflect code alert placement because it drives the care plan.
Incorrect MDS Coding for Anticoagulant Use: Two residents had MDS assessments that coded them as taking an anticoagulant, but their physician orders showed aspirin 81 mg daily and no anticoagulant medication. RN-A initially believed aspirin could be coded as an anticoagulant, then clarified it should be coded as an antiplatelet, and stated the MDS was coded incorrectly. The DON stated the MDS should be coded correctly based on RAI directions.
MDS coding was inaccurate for two residents. One resident’s MDS omitted an active dementia diagnosis despite provider documentation of vascular dementia, and another resident’s MDS incorrectly coded Trulicity as insulin even though the MAR showed no insulin use. The DON confirmed the dementia diagnosis and cognitive decline, and the IC-MDS stated she misunderstood Trulicity and did not realize the dementia diagnosis should have been included.
Incorrect Discharge MDS Coding: A resident admitted after left knee joint replacement received therapy and was discharged home, but the discharge MDS incorrectly coded the discharge destination as a short-term general hospital. The EMR and discharge plan of care both documented that the resident returned home with sister transportation, home health services arranged, and prescriptions sent to a local pharmacy. The CMDS verified the coding error.
Incorrect MDS Coding of Aspirin as an Anticoagulant: The facility failed to code MDS medication data accurately for four residents. In each case, aspirin was present on the MAR and medication review as an antiplatelet, but the MDS either omitted antiplatelet coding or incorrectly coded aspirin as an anticoagulant. RN-A stated he had always coded aspirin as an anticoagulant, and the DON stated MDS assessments should be coded accurately to reflect resident care needs.
Incorrect MDS Coding for Pressure Ulcer: A resident admitted with a sacral pressure ulcer and documented coccyx wound had an admission MDS that incorrectly indicated no unhealed pressure ulcers/injuries. Later MDS documentation, the care plan, and staff interviews confirmed the wound should have been coded as a pressure ulcer, and the MDS nurse acknowledged the coding error while the MDS specialist confirmed it was miscoded.
Two residents had quarterly MDSs with section C, the cognitive patterns section, left unassessed. Their EMRs did not include a progress note explaining the incomplete section, and an RN confirmed the omissions during interview.
A facility failed to accurately code MDS assessments for three residents. Two residents had Section GG dashed as not assessed on their most current MDS, and another resident’s MDS incorrectly showed no hospice care despite an active hospice order and staff confirmation that hospice services were in place. The MDSC stated Section GG was reviewed in team meetings and hospice status was based on a chaplain list, but the resident’s MDS still did not reflect the correct hospice information.
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