A resident with protein calorie malnutrition and a terminal prognosis was admitted on hospice with corresponding physician orders and a care plan, but hospice services were not coded on either the admission or quarterly MDS assessments. The MDS Coordinator and two MDS LPNs confirmed that, despite the resident receiving hospice care, Section O of both MDS assessments incorrectly indicated the resident was not on hospice, which the Administrator and DON acknowledged resulted in inaccurate MDS data.
An inaccurate MDS assessment failed to code a resident’s ordered CPAP use in Section O, even though the resident had diagnoses including OSA, COPD, asthma, and acute respiratory failure with hypercapnia. The resident was observed on supplemental O2 and reported using O2 daily and attempting to wear CPAP at night; the RN Case Mix Director and Administrator confirmed the respiratory treatments had not been coded on the MDS.
Surveyors found that MDS assessments were not accurately completed for two residents. One resident with multiple medical conditions, including epilepsy and vascular dementia, had a quarterly MDS that documented no falls, even though facility incident records and staff interviews confirmed an unwitnessed fall that led to hospital transfer. Another resident with peripheral vascular disease had an MDS indicating daily bed rail use, while observations over several days, the resident’s own statements, the care plan, and physician orders all showed that no bed rails were present or ordered. The MDS Coordinator and unit leadership acknowledged that the MDS coding for both residents was incorrect.
A resident with a stroke history, right-sided hemiplegia, and aphasia had multiple MDS assessments that coded no upper extremity impairment despite OT orders and staff confirmation of a right-hand contracture. During observation, the resident stated he could not open his right hand, and the MDSC acknowledged the assessments were inaccurate.
A resident with multiple psychiatric and cardiac diagnoses had an annual MDS completed with Section E (behavioral symptoms) coded as showing no behaviors, despite EMR documentation of hostility, disorientation, incontinence, paranoid statements, and unsafe smoking behavior involving staff intervention. The MDS Coordinator later acknowledged that the documented behaviors should have been coded on the MDS, and leadership stated that accurate behavior coding would have triggered a new care plan, while also noting the facility relies on the RAI Manual rather than a specific internal MDS policy.
A resident with multiple chronic conditions, severe cognitive impairment, and documented use of a manual wheelchair was placed in a Broda chair without a prior PT assessment, despite facility expectations that such devices be evaluated through a therapy referral. The resident’s MDS and care plan reflected wheelchair use, limited mobility with supervision, and no use of restraints or chairs that prevent rising. An LPN admitted the resident had not been assessed for the Broda chair, a restorative CNA was unaware of its use and reported the resident used a regular wheelchair and could stand, and a PTA confirmed there was no PT referral and no observed Broda chair use. Leadership staff acknowledged that, even when used for comfort and positioning, a therapy assessment should have been completed before using the Broda chair.
A resident who was diagnosed and treated for a multidrug-resistant E. coli UTI in the hospital did not have the infection coded on their quarterly MDS assessment upon return to the facility. Staff interviews revealed a misunderstanding of coding requirements and a lack of auditing to ensure MDS accuracy.
A resident with multiple chronic conditions was discharged home, but the facility incorrectly coded the discharge in the MDS as a hospital transfer and did not transmit a correction to CMS as required. Staff interviews revealed oversight and uncertainty in the discharge coding process, and the error was not identified or corrected in a timely manner.
Surveyors found that a resident did not receive an accurate assessment, as required, due to incomplete or inaccurate documentation of their condition or needs.
Two residents experienced significant weight loss that was not accurately coded in their MDS assessments. One resident with dysphagia lost over 8% of body weight, and another with Parkinson's disease lost over 13% in a month, but these losses were not documented in the MDS. Staff interviews confirmed the omissions, and the DON acknowledged the expectation for accurate MDS coding.
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