Inaccurate MDS Medication Reporting: A resident with Type 2 DM and other diagnoses had quarterly MDS entries that reported insulin injections in Section N, but the MAR showed no insulin administration and the only relevant order was for weekly semaglutide (Ozempic). The MDS Coordinator confirmed the resident received Ozempic, not insulin, and that no corrections or modifications had been submitted for the MDS assessments.
A resident’s MDS was inaccurate because malnutrition was not coded in Section I despite the resident’s admitting diagnosis of unspecified protein calorie malnutrition. The MDS listed multiple other diagnoses and a BIMS score of 15, and an MDS-LPN confirmed that malnutrition should have been marked.
The facility failed to accurately code MDS assessments for two residents. One resident received daily Aspirin, an antiplatelet, during the look-back periods for both a quarterly and annual MDS, but section N0415 item I was not coded to show antiplatelet use. Another resident had documented nightly BiPAP use on the TAR, but section O0110 item G2 on the comprehensive MDS was not coded to reflect BiPAP use. The MDSC confirmed both assessments were coded incorrectly.
A resident with dementia, metabolic encephalopathy, and restlessness/agitation was care-planned as an elopement risk/wanderer and had a Wanderguard in place, yet the MDS was not consistently coded for wandering. Survey observations showed the resident repeatedly wandering halls and approaching exit doors, and staff confirmed the resident wandered daily but was usually not charted unless exit seeking. The MDSC confirmed the MDS should have reflected the documented wandering behavior.
A facility inaccurately coded the MDS for two residents. One resident with OSA had TAR and PN documentation showing no CPAP equipment was available, yet the admission MDS coded use of a non-invasive mechanical ventilator. Another resident with dysphagia following a stroke received nutrition and hydration through tube feeding, but the admission MDS undercoded the extent of tube feeding and fluid intake. The DCS stated the facility followed the RAI manual and did not have a policy regarding MDS accuracy.
MDS assessments were coded inaccurately for 3 residents. One resident was coded as receiving an injection when the MAR, TAR, orders, and notes showed none were given, while two residents were coded as not receiving anticonvulsants even though orders and MARs showed they received Lamotrigine, Levetiracetam, or Gabapentin as ordered. The ADON and IDON confirmed the coding errors.
Inaccurate MDS Mood Coding: A resident with major depressive disorder had a PHQ-2 to 9 evaluation showing a score of zero, but the quarterly MDS recorded a score of 16, which reflects moderately severe depression. The SSC confirmed the evaluation was completed but not locked and acknowledged the MDS mood score was coded inaccurately.
Incorrect MDS Coding for Insulin Administration: A resident's Quarterly MDS was coded to show insulin use in section N0350, but MAR review showed the resident received Ozempic, not insulin, during the look-back period. The MDSC confirmed there was no insulin administration documented and that the Ozempic injection had been incorrectly coded as insulin.
MDS Coding Errors for High-Risk Medications: The facility failed to accurately code the MDS for multiple residents by omitting or misclassifying high-risk medications. Residents had documented orders and MAR entries for medications such as clonazepam, gabapentin, and Xarelto, but the MDS did not consistently reflect anticonvulsant or anticoagulant use, and an ADON confirmed several entries were coded incorrectly.
The facility failed to accurately code MDS assessments for two residents, including one resident who used CPAP nightly and another resident who received a regular diet but was coded for a mechanically altered diet. The facility also failed to fully complete a CAA for one resident, with multiple sections lacking required narrative and analysis, and failed to complete a PPS Discharge assessment when another resident’s payor source changed from Medicare to Medicaid.
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