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 failed to accurately code MDS assessments for three residents who wore wander guards and had physician orders for the devices. Each resident was observed with a wander guard in place, but the quarterly MDS assessments did not document a wander/elopement alarm. CNA and MDS staff confirmed the residents had wander guards, and the DON confirmed MDS accuracy is required using RAI Manual guidance.
MDS assessments were coded inaccurately for two residents. One resident's quarterly MDS showed anticoagulant use even though the resident was prescribed Plavix, an antiplatelet, and another resident with ESRD and hemodialysis had an annual MDS that did not document dialysis despite the resident's report and the MD order confirming treatment.
Inaccurate MDS coding affected multiple residents. A resident’s Tracking MDS listed the wrong admission date and entry type after a hospital return, another resident’s MDS incorrectly showed hospice services in the facility even though hospice had ended before admission, a resident with schizoaffective disorder and PTSD had MDSs that omitted those diagnoses, and another resident’s Tracking MDS listed reentry instead of admission. The NHA acknowledged the inaccuracies and stated the MDSs were being completed through a contracted agency.
A resident’s admission MDS inaccurately documented tracheostomy care in Section O0110, even though surveyor observation and interview confirmed the resident did not have a tracheostomy. The resident was admitted with dx including a right lower leg fracture, asthma, HTN, and A-fib, and the MDS also noted moderate cognitive impairment and independence with eating. The MDS Coordinator acknowledged the error and stated it was a mistake.
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