A resident’s Quarterly MDS failed to accurately reflect the presence of a suprapubic catheter and colostomy. The resident was observed with both devices in place, and record review showed active orders for catheter care and a colostomy, but the MDS coded the appliance section as none of the above. The RN/MDS nurse acknowledged the omission and confirmed the assessment was inaccurate.
A resident’s MDS was not accurately coded in Section P to reflect the use of a seat belt as a physical restraint during the assessment reference period. The MDS Nurse confirmed the seat belt was used and should have been coded, and the resident had unspecified dementia with no BIMS score, indicating severe cognitive impairment.
A resident's Quarterly MDS was coded to show tube feeding even though the resident had no feeding tube, received meals by mouth, and had an active order for a regular diet. The RD assessment, intake/output records, and clinical chart contained no evidence of enteral nutrition, and an LPN, DON, and Administrator all confirmed the MDS was coded incorrectly.
MDS Alarm Coding Error: A resident's MDS was not accurately completed in Section P because the resident's wheelchair alarm was not coded in Item P0200 despite a physician order for a chair alarm to be on and functioning properly. The MDS Nurse confirmed the alarm was in use during the assessment period and acknowledged it should have been included. The resident had Parkinson's disease, hemiplegia affecting the left nondominant side, and a BIMS score of 15.
A resident with dementia, hallucinations, anxiety, and agitation had a seat belt with alarm ordered for wheelchair use, and the facility had already identified the device as a physical restraint. However, the MDS coded no restraint use even though staff observed the resident wearing the belt, the resident could not independently remove it, and the MDS Nurse and DON confirmed it should have been coded as a restraint.
Inaccurate and incomplete MDS assessments were identified for three residents. Two residents had Entry and discharge-related MDS assessments left in In Progress status after hospital transfers and returns, and one resident’s MDS was coded as Death in Facility even though the resident died at the hospital after being sent out by EMS. The DON and RN confirmed the coding error and that some assessments were not up to date.
MDS inaccurately coded dialysis as not received. A resident with ESRD and dependence on renal dialysis had a physician order for dialysis on Monday, Wednesday, and Friday, and records showed dialysis treatments occurred during the MDS look-back period. CNA and LPN interviews confirmed the resident received dialysis, and the MDS nurse, DON, and Administrator all acknowledged the assessment should have been coded Yes rather than No.
A resident’s MDS incorrectly coded Section N as including antianxiety, antidepressant, hypnotic, and anticoagulant meds during the look-back period, but the MAR showed none of those meds were given. The MDS Nurse confirmed the error. The resident had metabolic encephalopathy and a BIMS score of 11, indicating moderate cognitive impairment.
A resident’s Significant Change MDS was coded to show a fall with major injury in Section J1900C, but the progress notes and Incident Log contained no record of such an event. The DON and MDS nurse both confirmed the coding was incorrect, and the resident’s record showed a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side.
Incorrect MDS Coding for Medications and Hospice Services: The facility inaccurately coded MDS assessments for three residents during the look-back period. One resident on an anticoagulant was not coded in Section N, another resident receiving hospice services was not coded in Section O, and a third resident was incorrectly coded as receiving an anticoagulant when the MAR showed an antiplatelet instead. The MDS nurse confirmed each error, and the affected residents had diagnoses including atrial fibrillation, COPD, and chronic medical conditions; two residents were cognitively intact and one had severe cognitive impairment.
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