Inaccurate MDS coding was found for two residents whose diabetes meds were non-insulin injectables. One resident with ESRD and diabetes had Ozempic ordered, and another resident with CKD and diabetes had Mounjaro ordered, but both MDS assessments incorrectly coded insulin use and hypoglycemic drug class use. The MDS coordinator acknowledged the coding error but did not update the assessments after learning of the inaccuracy.
MDS assessments were inaccurately coded for several residents. One resident with Chronic Bipolar Affective Disorder had a PASRR Level I outcome indicating the condition should be documented, but A1500 was coded no and A1510 was not completed. Another resident with bipolar II, depression, and anxiety was not properly referred for PASRR review and was also coded no at A1500. A third resident receiving regular dialysis had no dialysis documented on the admission MDS, and a fourth resident with a Level II PASRR and mental health diagnosis was also coded no at A1500.
MDS Assessment Not Accurately Coded for Active PTSD Diagnosis: A resident’s quarterly MDS failed to mark PTSD as an active psychiatric diagnosis in Section I even though the diagnosis had been added to the EMR before the assessment. The MDS RN acknowledged the diagnosis was active at the time of completion and stated she used UDA's, physician orders, diagnoses, progress notes, and staff interviews, along with the CMS RAI manual, when completing MDS assessments.
Inaccurate PASRR Coding on MDS Assessments: The facility failed to accurately code MDS A1500 for two residents with mental health diagnoses and PASRR findings. One resident had a Level II PASRR tied to bipolar disorder and other psychiatric diagnoses, and another resident had major depressive disorder, yet both MDS assessments were marked "No" for serious mental illness or related condition. The MDS/RN acknowledged the coding error for one resident and confirmed the other resident should have been coded "Yes."
The facility failed to accurately code MDS assessments for two residents. One resident with Alzheimer’s disease, major depression, anxiety, and a psychotic disorder had MDSs that did not indicate a Level II PASRR despite prior PASRR approval for an unlimited LTC stay, and the MDS coordinator acknowledged the error. Another resident admitted with PTSD had an admission MDS that did not mark PTSD as an active diagnosis, and the MDS coordinator acknowledged the diagnosis was present on admission and that psychiatric services had been provided.
Inaccurate MDS coding was found for PASRR status, insulin use, and psychotropic medications. Two residents with approved PASRR Level II determinations were coded as not having PASRR Level II, one resident receiving glargine and aspart insulin was coded as not receiving insulin, and two residents had incorrect psychotropic medication coding, including one coded for an anti-anxiety med that was not ordered and another coded as not receiving an antipsychotic despite an order for Rexulti. The MDS RN verified the errors, and the DON stated the MDS should be coded accurately.
Inaccurate PASRR coding was found on comprehensive MDS assessments for two residents. One resident had diagnoses including schizoaffective disorder, bipolar type, TBI, and epilepsy, and his PASRR outcome explanation said A1500 should be coded yes, but the MDS coded A1500 no and left A1510 blank. Another resident with anxiety, behavior, psychotic, and mood disturbance diagnoses also had a PASRR outcome explanation directing A1500 to be coded yes, yet the MDS coded A1500 no and left A1510 blank; the SW said she completed A1500 and the RN/MDS coordinator confirmed the item should have been coded yes.
MDS assessments were inaccurately coded for medications and PASRR status for multiple residents. One resident’s MDS failed to identify an antidepressant despite an active Escitalopram order, and two residents had PASRR-related coding errors on comprehensive MDS assessments even though records showed serious mental illness and/or a PASRR Level II status. Interviews confirmed the RN/MDS coordinator acknowledged the miscoding, while SSD completed PASRR screenings and the RN/MDS coordinator entered the MDS data.
Inaccurate MDS Ventilator Coding: A resident’s quarterly MDS was incorrectly coded to show use of both an invasive mechanical ventilator and a non-invasive mechanical ventilator, even though she was observed on oxygen via nasal cannula, denied ventilator use, and had no physician order, care plan indication, or facility history supporting ventilator use. The MDS nurse acknowledged the coding errors, and the DON confirmed the resident did not use either type of ventilator.
MDS PASRR coding was inaccurate for two residents. One resident with major depressive disorder, OCD, anxiety disorder, and paranoid schizophrenia had a level II PASRR on file, but multiple comprehensive MDS assessments coded A1500 as No. Another resident with delusional disorders had a PASRR Outcome Explanation stating the facility should mark A1500 Yes, yet her comprehensive MDS also coded No. The SSC confirmed both assessments should have been coded Yes, and the administrator expected accurate MDS coding.
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