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.
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.
MDS coding was inaccurate for two residents. One resident with NSTEMI was receiving clopidogrel, an antiplatelet, but the MDS marked Antiplatelet as No instead of Yes. Another resident with Bipolar Disorder had a PASRR Level II determination, but the significant change MDS marked PASRR as No and skipped the related Level II section even though staff confirmed the resident should have been coded as Yes.
MDS coding was inaccurate for a resident with severe cognitive impairment, delusions, and dementia with psychosis. Although the resident had an order for Risperdone and informed consent for antipsychotic use, the MDS did not identify antipsychotic medication in section N and was instead coded as an antianxiety medication. Interviews also confirmed that AIMS monitoring was not completed as expected, and the behavior committee and pharmacy reviews noted the antipsychotic use and hallucinations/delusions without identifying the missing AIMS assessment.
Incomplete CAA Documentation for Two Residents: The facility failed to complete required CAA documentation for two residents after their MDSs triggered multiple care areas. For both residents, the analysis of findings lacked narrative describing the relationship between risk factors and confounding problems, and the care plan considerations sections repeatedly listed Visual Functions without an overall objective, impact statement, or rationale. The MDSC confirmed the CAAs were not completed as outlined in facility policy.
A resident with renal insufficiency received dialysis three times per week, and facility transport staff were observed bringing the resident back from the dialysis center with a dressing on the right forearm from treatment. However, the MDS did not mark dialysis in the special treatments section, and the DON confirmed the assessment should have identified the resident’s dialysis need.
Two residents’ MDS assessments incorrectly indicated insulin injections were being given even though physician orders showed no insulin orders. Both residents had Type 2 DM and BIMS scores of 0, and the MDS Coordinator confirmed the entries were coded incorrectly; the residents received Ozempic during the look-back period, which is not insulin.
MDS coding was inaccurate for two residents. One resident with Type 2 DM was incorrectly coded as having an ostomy and as receiving an insulin injection during the lookback period, even though the EMHR showed no ostomy and no insulin orders. A second resident with Type 2 DM was also incorrectly coded as receiving an insulin injection during the lookback period, despite no EMHR evidence of insulin orders; the MDSC confirmed the errors.
MDS inaccurately coded a resident as receiving an anticoagulant when the resident had not taken one since admission. The resident was cognitively intact, was admitted on Plavix, and the RN confirmed the MDS was marked incorrectly; CMS RAI guidance states clopidogrel is not to be coded as an anticoagulant.
Inaccurate MDS coding was identified for two residents. One resident’s PASRR level 2 screen showed MMI, but the MDS stated the resident had not been determined to have a serious mental illness, ID, or related disorder. Another resident’s MDS listed a psychotic disorder, while the care plan listed other mental health diagnoses but no psychotic disorder. RN-B confirmed both MDS assessments were not coded accurately.
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