MDS assessments were coded inaccurately for two residents. One resident with dementia, anemia, and PE was documented as having internal bleeding despite no supporting documentation, and staff confirmed the entry was an error. Another resident with urinary retention, BPH, and obstructive/reflux uropathy returned with a foley catheter and had a catheter care plan, but the MDS failed to code the indwelling urinary catheter; staff said the information had been entered for another resident.
Inaccurate MDS coding affected two residents: one resident with a urinary catheter was assessed as having no indwelling catheter despite observations, physician orders, and care plan documentation showing catheter use, and another resident was assessed as having no wander alert bracelet despite repeated observations, TAR entries, physician orders, and the care plan showing the bracelet was in place. The MDS assessor and MDS Coordinator acknowledged the missed coding and responsibility for accurate assessment completion.
A resident with dementia and other diagnoses had an MDS that documented moderate cognitive impairment but failed to code the use of a wander/elopement alarm. Records and staff interviews showed the resident was at risk for elopement, had physician orders for a wander guard on the right wrist, and the device was observed in use, yet it was omitted from the assessment as an oversight.
MDS inaccurately documented indwelling catheter status. A resident admitted with urinary-related diagnoses did not have an indwelling catheter, as shown by the PRI, nursing assessment, progress note, staff interviews, and observation, yet the admission MDS auto-populated that the resident had a Foley and was always continent. The MDS Assessor said the error came from prior CNA task information carried over from a previous admission and was not corrected, and the DON stated the MDS should have been clarified with nursing staff.
The facility failed to ensure accurate MDS coding of current tobacco use for multiple cognitively intact residents who were active smokers. Several residents with conditions such as COPD, pulmonary fibrosis, heart failure, schizophrenia, paraplegia, hypertensive heart disease, epilepsy, and depression were repeatedly observed smoking in the designated smoking room. Each had a signed smoking agreement, a smoking assessment identifying them as smokers, and a care plan addressing smoking in a designated area, yet their admission, annual, or significant-change MDS assessments did not reflect current tobacco use in Section J1300. The MDS Manager reported that Section J1300 is completed by the MDS department using resident assessments, staff interviews, medical record review, and a periodically updated smoking list from recreation, but was not aware of these specific discrepancies.
An MDS assessment inaccurately recorded no UE or LE impairment for a resident with documented contractures, left-sided hemiplegia, impaired ROM, and dependence for transfers with a Hoyer lift and splint/brace use. Records from nursing, PT, and OT all showed contracture-related limitations, and staff interviews confirmed the resident had contractures that began before or continued after admission, but the MDS coordinator did not reflect that information in the quarterly assessment.
A resident’s comprehensive MDS did not accurately code tobacco use, even though the care plan identified the resident as a known smoker and staff observed the resident smoking without difficulty. The MDS Coordinator stated the tobacco section was missed because the smoking list from activities was not received, and the assessment was coded as not using tobacco despite the resident’s smoking status.
Inaccurate MDS Documentation of Restraint Use: An MDS assessment incorrectly stated that a resident used a physical restraint in a chair or out of bed, even though the resident was observed in a Geri chair with no restraint. Record review found no physician orders or care plan evidence of restraint use, and staff confirmed the Geri chair was used for positioning, fall risk reduction, and skin integrity rather than as a restraint.
A resident with multiple complex medical conditions, including cellulitis, bacteremia, and numerous documented wounds (e.g., Stage III sacral ulcer, deep tissue injuries to hips and heels, unstageable hip wound, gangrenous toes, and a left bunion wound), was admitted and readmitted with detailed hospital records and facility admission notes describing these skin issues. Despite this, MDS assessments in two separate assessment periods documented no skin problems or only moisture-associated skin damage, omitting the full-thickness wounds, pressure injuries, and gangrene. The MDS coordinator and MDS director reported relying on the wound nurse’s documentation and the medical record without physically assessing the resident or reconciling discrepancies between hospital discharge information and internal wound assessments, resulting in inaccurate MDS coding of the resident’s skin condition.
A resident with dementia, seizure disorder, and COPD had a care plan indicating dependence for bed mobility with a need for total assistance from two staff, but the MDS assessment was inaccurately coded as requiring only partial/moderate assistance. Observation showed two staff providing total assistance for bed mobility, and interviews with an RN, a CNA, and the rehab director all confirmed the resident required total care with two-person assistance for bed mobility and transfers. The rehab department completed the MDS bed mobility section, and the rehab director later acknowledged the coding error, while the MDS coordinator stated they were unaware of the discrepancy despite their usual process of using assessments, staff interviews, and record review for MDS completion.
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