Inaccurate MDS Coding for ADLs, Restraints, Falls, and Hospice Services
Summary
The deficiency involves the facility’s failure to complete accurate Minimum Data Set (MDS) assessments in accordance with the Resident Assessment Instrument (RAI) User’s Manual, resulting in multiple residents’ clinical status not being correctly reflected. For one resident with dementia and severe cognitive impairment, the Significant Change and subsequent Quarterly MDS assessments coded him as always incontinent of bladder and independent with eating and upper body dressing, with use of a walker and wheelchair. However, the electronic medical record showed ongoing indwelling catheter care each shift and no documentation of walker use, wheelchair mobility, or dressing requirements during the review period. Staff interviews revealed that this resident had an indwelling catheter for more than a year, had not walked for several years, and was dependent on staff for all ADLs, including dressing and wheelchair positioning, contradicting the MDS coding. Observations showed the resident slumped in a wheelchair, wearing a hospital gown over clothing, with a visible catheter bag on his lower leg and feet frequently skimming the floor despite foot pedals being present, further indicating dependence and catheter use not accurately captured on the MDS. Another deficiency involved a resident with a history of stroke, hemiplegia, and hemiparesis whose Significant Change MDS coded the use of “other restraint.” During observation, the resident was seen in bed with bilateral grab bars at the head of the bed and her right arm positioned on a pillow. The resident reported using the grab bars to help move and reposition herself in bed. CNAs and administrative nursing staff confirmed that the facility did not use restraints and that the grab bars were used as enablers to assist residents with repositioning and to increase independence. Administrative staff acknowledged that the MDS coding for restraints was inaccurate because the grab bars did not limit the resident’s voluntary movement or access to her body. A further inaccuracy was identified for a resident with diabetes, atrial fibrillation, unsteadiness of feet, and a toe fracture. Both a Significant Change and a Quarterly MDS documented intact cognition, partial/moderate assistance with transfers, no ambulation, and no falls. However, progress notes in the EMR documented two unwitnessed falls during the look-back period, including one where the resident was found on the floor next to the bed with a forehead skin tear and another where the resident was found sitting on a fall mat on the floor with a scratch on the ankle. These documented falls were not reflected on the MDS. In addition, another resident with diabetes, depression, CAD, and chronic kidney disease had a Significant Change MDS that coded no hospice services, while the EMR contained a hospice certification and physician orders initiating hospice services, and social service notes and staff interviews confirmed that hospice services, including bathing by a hospice aide, were being provided during the look-back period. The consultant MDS nurse confirmed that these assessments were inaccurate and not completed in accordance with the RAI User’s Manual, constituting significant errors in coding for urinary status, ADL dependence, restraints, falls, and hospice services. The consultant MDS nurse stated that the resident with the indwelling catheter should have been coded as not rated for urinary continence due to catheter placement rather than as always incontinent, and that his ADL status should not have been coded as independent given his dependence on staff for dressing and wheelchair positioning. For the resident with grab bars, the nurse confirmed that the grab bars were used as enablers and not as restraints, making the restraint coding inaccurate. For the resident with documented falls, the MDS failed to capture falls that occurred within the look-back period, and for the resident receiving hospice services, the MDS did not reflect hospice care that was active during the look-back period. These miscodings met the RAI Manual’s definition of significant error, in which the resident’s overall clinical status is not accurately represented on the assessment and the error has not been corrected by a more recent assessment.
Penalty
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The facility failed to accurately code MDS assessments for six residents, leading to deficiencies in their comprehensive assessments. For example, one resident with severe cognitive impairment had an MDS assessment lacking functional status documentation, while another resident's dental issues were not accurately documented. The facility did not have a specific MDS completion policy but claimed to follow the RAI manual guidelines.
The facility failed to ensure accurate completion of MDS 3.0 assessments for four residents, resulting in multiple sections being marked as 'not assessed' or left with dashes. This was due to staff not completing their assigned sections timely, as verified by an RN.
The facility failed to accurately code comprehensive assessments for two residents, leading to deficiencies in their medical records. One resident's opioid use and discharge status were incorrectly documented, while another resident's fall was not recorded in the annual MDS assessment.
The facility failed to ensure accurate resident assessments, affecting three residents. One resident's fall and hearing loss were not correctly documented, another's vision and dental issues were overlooked, and a third resident's dental status was inaccurately recorded.
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in their medical records. One resident's hyperlipidemia and medication were not properly documented, another resident's vision impairment was not accurately assessed, and a third resident's dental issues were not recorded. These errors were confirmed through staff interviews and record reviews.
The facility failed to ensure accurate assessments for multiple residents, including incorrect coding of hospice services, discharge destinations, oral health status, and alarm use. These discrepancies were confirmed through interviews and record reviews, highlighting significant deficiencies in the facility's assessment processes.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for six residents, leading to deficiencies in their comprehensive assessments. For instance, Resident #01, with severe cognitive impairment and multiple medical diagnoses, had an annual MDS assessment that lacked documentation to support the assessment of functional status, with section GG left blank. Similarly, Resident #24, who was cognitively intact, had a quarterly MDS assessment that also lacked documentation of functional status, with section GG left blank. The facility did not have a specific MDS completion policy but claimed to follow the RAI manual guidelines. Further deficiencies were noted for other residents. Resident #41, with multiple medical conditions including cognitive impairment, had an MDS assessment that failed to provide an assessment related to the level of care required. Resident #74, dependent on staff for medication administration, had an MDS assessment that did not assess his functioning level. Residents #92 and #82 had MDS assessments that inaccurately documented their dental status, despite observations and interviews confirming dental issues. The Regional MDS Nurse and RN confirmed the inaccuracies in the MDS assessments for these residents, indicating a failure to follow the RAI manual guidelines.
Inaccurate Completion of MDS Assessments
Penalty
Summary
The facility failed to ensure that assessments were accurately completed for four residents, affecting their Minimum Data Set (MDS) 3.0 assessments. Resident #77, admitted with diagnoses including dementia, anxiety, and pain, had multiple sections of the MDS assessment marked as 'not assessed' or left with dashes, including cognition, mood, behaviors, and pain. This was verified by RN #1141, who stated that the incomplete sections were due to other staff not completing their assigned parts of the assessment timely. Similar issues were found with Resident #110, who had diagnoses including dementia, diabetes, and depression. The annual MDS assessment for this resident also had multiple sections marked as 'not assessed' or left with dashes, including cognition, mood, behaviors, and preferences for routine and activities. RN #1141 confirmed these deficiencies, attributing them to staff not completing their sections on time. Resident #217, diagnosed with Alzheimer's disease, hypertension, and depression, had an incomplete quarterly MDS assessment, particularly in the section related to pain assessment. The questions were either not answered or marked as 'not assessed.' RN #1141 verified this issue, again citing staff delays in completing their sections. Lastly, Resident #281, with Alzheimer's disease and diabetes mellitus, had a comprehensive MDS assessment with multiple sections, including cognition and mood, marked as 'not assessed' or left with dashes. RN #1141 confirmed the inaccuracies, attributing them to the same issue of staff not completing their assigned sections timely.
Inaccurate Coding of Comprehensive Assessments
Penalty
Summary
The facility failed to accurately code comprehensive assessments for two residents, leading to deficiencies in their medical records. Resident #88, who had multiple diagnoses including surgical aftercare, diabetes, stroke, and end-stage renal disease, was admitted with an order for oxycodone for pain management. Despite receiving oxycodone for severe pain during a dressing change, the admission MDS assessment incorrectly indicated that the resident did not receive any opioids. Additionally, the discharge assessment for Resident #88 was inaccurately coded as a transfer to the hospital, whereas the resident was discharged against medical advice and arranged for a ride home. Resident #54, diagnosed with vascular dementia, adult failure to thrive, hyperlipidemia, chronic kidney disease, and hypertension, had an annual MDS assessment that failed to document a fall that occurred on 09/19/23. The assessment incorrectly indicated that no falls had occurred since the prior assessment. The MDS RN confirmed the error, acknowledging that the resident did have a fall, which was not reflected in the assessment. These inaccuracies in coding comprehensive assessments highlight deficiencies in the facility's record-keeping and assessment processes.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure resident assessments were accurately completed, affecting three residents out of 23 reviewed. Resident #68's comprehensive Minimum Data Set (MDS) assessment did not accurately capture a fall that occurred on 12/19/23, and the resident's hearing ability was also incorrectly coded. Despite having severe hearing loss in both ears, the MDS assessment indicated adequate hearing. Additionally, the resident's plan of care noted potential communication and hearing deficits, which were not accurately reflected in the MDS assessment. Resident #4's most recent annual MDS assessment inaccurately reported no issues with vision or dental health, despite the resident stating the need for dental and ophthalmological care. Similarly, Resident #13's MDS assessment did not reflect the resident's dental status, as broken and missing teeth were observed during a survey. Corporate MDS staff confirmed the inaccuracies in the assessments for all three residents, indicating a failure in the facility's assessment process.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed accurately for three residents, leading to discrepancies in their medical records. Resident #31's quarterly MDS assessment did not accurately reflect the diagnosis of hyperlipidemia, despite the resident receiving Atorvastatin for this condition. Additionally, the MDS inaccurately indicated that the resident had received an anticoagulant, which was not the case. These errors were confirmed by the facility's MDS Coordinator, RN #310, during an interview. Resident #23's quarterly MDS assessment inaccurately documented the resident's vision status as adequate, despite the resident reporting significant vision impairment and the need for new glasses. The Social Services Designee (SSD) #347, who completed the vision section of the MDS, admitted to not asking the resident or staff about the resident's visual function and instead relied on observations and previous MDS assessments. This led to the resident not receiving the necessary eye care and glasses. Resident #8's significant change MDS assessment failed to document the resident's dental issues, despite the resident having dental caries and broken teeth as noted in the dental plan of care and dental notes. The MDS Nurse #335 confirmed that the MDS was inaccurately coded, as the resident's dental issues were present at the time of the assessment. The resident reported poor dental condition and the need for tooth extraction, which had not been addressed. These deficiencies highlight the facility's failure to ensure accurate and comprehensive MDS assessments for its residents.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure accurate assessments for multiple residents, as evidenced by discrepancies in the Minimum Data Set (MDS) 3.0 assessments. For instance, Resident #62, who was admitted with diagnoses including dementia and Alzheimer's disease, was incorrectly coded in the MDS assessment as not receiving hospice services despite being on hospice care. This error was confirmed by the MDS Director during an interview. Similarly, Resident #114's discharge MDS assessment was inaccurately coded as a discharge to a short-term general hospital, whereas the resident had actually moved out of state to live with a friend. This mistake was also acknowledged by the MDS Director upon review. Additionally, Resident #37's oral health evaluation was inaccurately documented, failing to note the resident's missing upper dentures, which were reported lost by the resident and confirmed through interviews with staff and the resident herself. The MDS Director admitted that the oral evaluation was not accurately assessed. Furthermore, the facility incorrectly coded the use of alarms for multiple residents in the memory care unit. The MDS assessments for these residents indicated daily use of alarms, but there was no evidence in the medical records to support this. The MDS Coordinators verified that the coding was based on the presence of alarmed entrance and exit doors in the memory care unit, which is not in accordance with the MDS 3.0 Resident Assessment Instrument User's Manual guidelines. This widespread inaccuracy in resident assessments highlights significant deficiencies in the facility's assessment processes.
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