A resident with diabetes had quarterly MDS assessments that incorrectly coded insulin use despite current orders showing weekly semaglutide injections and no insulin orders. The resident stated she did not receive insulin, and an RN confirmed the MDS was coded incorrectly and needed modification. The DON stated the MDS should accurately reflect each resident’s status.
A resident’s quarterly MDS failed to code use of a non-invasive ventilatory device, even though a BiPAP machine was observed at bedside and the resident stated staff assisted with it at night. The chart also included orders for CPAP/BiPAP use for OSA, and the MDS coordinator confirmed the assessment was coded incorrectly.
A facility failed to accurately code MDS assessments for code alert device use for multiple residents identified as at risk for elopement and wandering. Although a wander guard log showed several residents had code alert devices, the MDS often stated the devices were not in use and did not reflect wandering behavior. Several care plans also lacked elopement or wandering interventions, and staff interviews confirmed the MDS should reflect code alert placement because it drives the care plan.
Incorrect MDS Coding for Anticoagulant Use: Two residents had MDS assessments that coded them as taking an anticoagulant, but their physician orders showed aspirin 81 mg daily and no anticoagulant medication. RN-A initially believed aspirin could be coded as an anticoagulant, then clarified it should be coded as an antiplatelet, and stated the MDS was coded incorrectly. The DON stated the MDS should be coded correctly based on RAI directions.
A resident with multiple medical conditions and at moderate risk for pressure sores had inconsistent wound documentation, including varying descriptions and stages of pressure ulcers. An RN coded the MDS based on incomplete and conflicting nursing data, resulting in inaccurate staging of the resident's pressure ulcers.
A resident with hemiplegia and hemiparesis experienced multiple documented falls after admission, but the 5-day MDS assessment was inaccurately coded to indicate no falls had occurred. The MDS-RN acknowledged missing the falls during the assessment process, despite facility policy requiring consistency between MDS data and resident records.
Two residents had inaccurate MDS assessments, including one who was incorrectly documented as receiving insulin injections when only non-insulin diabetes medications were administered, and another who was coded with a dementia diagnosis not supported by the medical record. Nursing staff and the DON confirmed these errors after review.
A resident with type 2 diabetes and other comorbidities was prescribed Trulicity, a GLP-1 medication, but two consecutive MDS assessments incorrectly coded this medication as insulin. The error was identified through document review and staff interviews, which revealed that MDS assessments were completed offsite and that there may be a lack of staff training regarding GLP-1 medications. Facility policy requires accurate documentation from multiple sources, but this was not followed, leading to the deficiency.
Two residents with documented mental illness were not accurately identified as such in their MDS assessments, despite PASRR findings and diagnoses. Staff interviews confirmed the omission, and facility policy lacked details on ensuring assessment accuracy or staff training.
A resident's MDS assessment was inaccurately coded to indicate receipt of insulin injections, although medication records and physician orders confirmed no insulin was administered. The resident, who has diabetes, was treated with oral diabetic medications, and the error was attributed to misclassification of an oral agent as insulin. The facility lacked a specific MDS policy.
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