A resident receiving dialysis three times weekly was not coded for dialysis in Section O on two quarterly MDS assessments. The MDS Nurse confirmed the resident attended all scheduled dialysis treatments but did not code them because dialysis center communication sheets were unavailable during the look-back period. The resident had ESRD and dependence on renal dialysis, and the ADM stated the MDS should accurately reflect dialysis services.
Inaccurate MDS Bladder Assessment: A resident’s MDS failed to document an indwelling urinary catheter in Section H even though observation and the TAR showed a catheter and catheter bag order in place. The MDS nurse confirmed the assessment error, and the resident had diagnoses including diverticulosis and a stage 3 sacral pressure ulcer, with BIMS indicating cognitive intactness.
Incorrect MDS Section N Coding for Medication Use: Two residents had inaccurate MDS coding related to medication use. One resident’s MDS did not reflect documented anti-anxiety medication administration despite an active Clonazepam order for anxiety, and another resident’s MDS incorrectly showed insulin injections even though the MAR showed no insulin was given during the month. The MDS Coordinator confirmed the coding errors and stated she was responsible for reviewing assessments before signing and submitting them.
A resident with Alzheimer's Disease and severely impaired cognition was incorrectly coded on the MDS as receiving an antipsychotic medication even though there were no physician orders and no MAR documentation showing the medication was given during the lookback period. RN and DON review confirmed the MDS was coded inaccurately based on the source documents.
A resident with a diagnosis of tobacco use was observed going outside for smoke breaks, and staff confirmed the resident smoked daily. However, the MDS was coded as no tobacco use even though the resident's smoking screening documented tobacco use and the RN who completed the assessment said the entry was made in error.
A resident's Quarterly MDS was inaccurately coded in Section GG as having no upper extremity impairment even though observation showed bilateral hand contractures and the DON confirmed the resident had contracted hands and was supposed to have hand splints. The resident had diagnoses including type 2 diabetes and right-hand contracture, and a BIMS score of 9 indicating moderate cognitive impairment. Facility policy required staff completing the assessment to certify the accuracy of their portion of the MDS.
Inaccurate MDS Weight Loss Coding: A resident with CHF had documented weight loss of 21 pounds, or 8.3%, in one month, but section K0300 of the MDS was coded as not showing a 5% or greater loss. The MDS nurse confirmed the error and stated the weight loss should have been coded. A BIMS was not completed because the resident was rarely/never understood.
A resident’s annual and quarterly MDS assessments were both incorrectly coded as indicating anticoagulant therapy, even though the physician orders did not show any anticoagulant medication. The MDS nurse confirmed the coding error was an oversight, and the DON stated that MDS accuracy is crucial because it informs resident care, interventions, diets, fall risk, and medication plans.
A resident’s quarterly MDS was coded incorrectly in Section N to show insulin injections when the MAR showed no insulin order and no insulin administration. The MDS Coordinator confirmed the error and stated the resident only received a flu shot, while the resident’s record also showed dementia and an inability to complete the BIMS interview.
A resident’s Annual MDS was coded incorrectly in Section A1500t regarding whether the resident was currently considered by the state level II PASRR process to have SMI and/or ID or a related condition. The record showed diagnoses including mood disorder and psychotic disorder with delusions, and the MDS also documented psychotic disorder in Section I. An MDS RN confirmed the item was answered incorrectly and stated the inaccurate coding could prevent the resident from receiving needed services.
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