Inaccurate MDS Pneumonia Coding: A resident’s quarterly MDS incorrectly documented pneumonia within the previous 7 days even though the resident’s chart reflected a prior pneumonitis diagnosis that had been treated and resolved. The MDS Coordinator stated the pneumonia entry auto-populated from the earlier diagnosis, and the Medical Director confirmed the MDS was inaccurate and that the resident had not had a pneumonia diagnosis since the prior year.
A facility failed to ensure MDS accuracy for 3 residents. One resident’s Significant Change MDS omitted a UTI diagnosis after treatment with IV antibiotics, another resident’s MDS did not include an active stage 4 sacral pressure ulcer documented by the wound care provider, and a third resident’s Quarterly MDS omitted a UTI despite provider orders and nursing notes showing treatment with oral Cipro.
A resident’s MDS was inaccurate because insulin use was documented in the insulin section but not in the high-risk drug classes section, even though the resident had an order for daily Lantus for diabetes mellitus. The MDS Coordinator confirmed the omission during interview.
A resident with aphasia, dysphagia, and dementia had MDS assessments that documented clear speech and no communication difficulty, even though the resident’s daughter and an LPN stated the resident had been non-verbal and unable to speak clearly. The MDS Coordinator acknowledged the MDS was inaccurate and should have reflected the resident’s non-verbal status.
The facility failed to ensure MDS assessments accurately reflected the clinical status of two residents. One resident with depression was receiving amitriptyline, but the MDS incorrectly stated no antidepressant use and also noted scheduled pain meds that were not given. Another resident with low back pain had an order for tramadol, but the MDS incorrectly stated no opioid use; the MDS coordinator confirmed both assessments were inaccurate.
Inaccurate and Incomplete MDS Assessments: The facility failed to ensure two residents’ MDSs were accurate and complete. One resident with dementia, cognitive impairment, dysphagia, and muscle wasting was documented as having clear speech even though nursing notes and an LPN and CNA described the resident as non-verbal. Another resident’s re-entry MDS was missing the mood and mood interview section, which the MDS Coordinator, DON, and Administrator stated should have been completed.
A resident’s MDS was inaccurate for a pressure wound review. The resident had a right heel deep tissue injury that later healed, but the Quarterly MDS still documented a pressure ulcer even though the wound was no longer present when the assessment was completed. The MDS coordinator confirmed the wound had healed and that it should not have been recorded as present.
The facility failed to accurately complete MDS assessments for two residents by not correctly coding their scheduled medications. One resident had a physician order for daily Aspirin EC 81 mg for pain, but the quarterly MDS documented that the resident did not receive scheduled pain meds, which the MDS coordinator acknowledged was inaccurate. Another resident had a physician order for Depakote 250 mg three times daily for major depressive disorder, yet the quarterly MDS indicated the resident did not receive anticonvulsant meds; the MDS coordinator confirmed Depakote is an anticonvulsant and that this MDS entry was incorrect.
A resident returned from a hospital stay and did not receive the required comprehensive head-to-toe assessment upon readmission. EHR review showed no complete assessment was documented, and the DON confirmed that the assessment, including a full skin check, was not performed despite facility expectations that all residents returning from the hospital be assessed on arrival. This failure was noted as likely to affect accurate calculation of the resident’s risk score for skin breakdown or falls.
A resident’s admission MDS inaccurately documented the presence of a Foley catheter, even though the resident did not have one. During observation, the resident was seen without a Foley catheter, and the UM later confirmed that the MDS entry indicating a Foley catheter was marked in error. This reflects a failure to accurately assess and document the resident’s catheter status on the MDS.
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