A resident with dementia, PTSD, anxiety disorder, and major depressive disorder had a PASARR level II screen in the record, but two MDS assessments coded Section A1500 as “No” for PASRR serious mental illness/intellectual disability status. The MDS coordinator later acknowledged one MDS was coded incorrectly and could not explain the earlier error.
A resident’s discharge MDS was not completed after the resident was discharged home. The MDS coordinator said the discharge was missed because they were off when the resident left and the resident was not on the planned discharge list; the NHA stated a discharge MDS should be completed when the discharge occurs and that there should be a process to prevent residents from being missed.
A resident admitted with PTSD did not receive a completed trauma-informed assessment or plan of care on admission. Review of records showed no trauma-informed assessment, and the NHA confirmed the PTSD questionnaire was not completed. The SW stated they had not been trained on the trauma-informed care process and did not complete the questionnaire because they believed there were no issues.
A resident’s MDS was coded inaccurately in section A by indicating the resident did not meet the federal definition of serious mental illness, even though the resident had diagnoses of depression, anxiety, PTSD, personality disorder, mood disorder, and altered mental status, along with multiple psychotropic meds and regular antipsychotic use. The resident’s PASARR screen and care plan also reflected a major mental disorder, and SS later confirmed the MDS coding was incorrect.
A resident with depression, PTSD, dementia with anxiety, adjustment disorder, anxiety disorder, and other psychotic disorders had an annual MDS that coded PASRR Level II status as No, even though the record included a completed PASARR Level 2 screen. During survey review, the NHA acknowledged the MDS was coded in error.
A resident’s MDS assessments were not coded correctly for dental status. The resident stated he had no teeth and no dentures since admission, and the MDS Coordinator acknowledged awareness of this but did not know why the assessments after admission were marked incorrectly.
A facility failed to ensure accurate MDS coding for three residents. One resident who received dialysis and took an antiplatelet medication was coded as not receiving dialysis and as receiving an anticoagulant instead. Another resident who regularly smoked was coded as not using tobacco. A third resident was coded as using a restraint and alarms less than daily, but observation and staff interview showed no restraint or motion alarm use.
A resident’s MDS did not accurately code her pressure injuries. Hospice and the NP documented a large coccyx wound with undermining and necrotic areas on both buttocks, and the NP identified unstageable ulcers of the coccyx and left buttock and a stage 3 ulcer of the right buttock. Despite this, the MDS marked unhealed PI/injury as “NO,” and an RN confirmed that MDSs should be completed accurately and should document the resident’s PIs.
MDS assessments were inaccurately coded for three residents. One resident’s transmitted MDSs used a different first name than the resident’s legal name, another resident’s PASRR Level II showed serious mental illness but the MDS did not reflect it, and a third resident’s MDS incorrectly indicated anticoagulant use despite no current anticoagulant order or administration. The MDSC verified the coding errors in the assessments.
The facility inaccurately coded MDS assessments for multiple residents. One resident with a tracheostomy was incorrectly coded as comatose and the trach was omitted; another resident was also incorrectly coded as comatose. A resident receiving Hospice was not coded as such, a resident on levetiracetam was not coded for anticonvulsant use, a resident was incorrectly coded as receiving insulin despite no insulin order, and a resident with a Foley catheter was not coded as having a catheter. MDSC-N confirmed several of the coding errors, and the DON and NHA confirmed the Hospice coding error.
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