A resident with type 2 DM and hyperglycemia had a physician order for daily Lantus insulin injections, which were administered and documented on the MAR. However, the quarterly MDS completed by the MDS Coordinator did not reflect that the resident received insulin injections or hypoglycemic medication. In interviews, the MDS Coordinator acknowledged overlooking and incorrectly coding these medications, and both the corporate MDS coordinator and the DON confirmed that the resident had been receiving daily insulin and that the MDS should have accurately captured relevant medications.
A resident was admitted with a documented sacral pressure-related skin condition, including nursing notes describing reddened areas on the inner/top buttocks treated with foam dressings and physician-ordered wound care. However, the admission MDS was coded as if the resident had no unhealed stage I pressure ulcer during the look-back period. In interviews, the MDS coordinator, DON, and Administrator all acknowledged that the admission MDS should have been coded to reflect a stage I pressure ulcer present on admission.
Surveyors found that MDS assessments were inaccurately coded for two residents: one resident receiving clopidogrel was incorrectly coded as taking an anticoagulant instead of an antiplatelet, and another resident with severe dementia who wore a wander/elopement alarm bracelet was not coded for alarm use on the quarterly MDS. The MDS nurse reported she misinterpreted an order referencing anticoagulant monitoring in the first case and did not code the alarm in the second case because there was no physician order, despite knowing the alarm was in place and it being documented in the care plan and elopement risk assessment.
A resident with bipolar disorder, dementia with behavioral disturbances, and anxiety disorder had a physician order for lamotrigine 25 mg PO BID, which was administered as ordered and documented on the MAR during the MDS 7-day lookback period. However, the quarterly MDS assessment completed by a per diem MDS nurse did not code the resident for anticonvulsant medication use. Subsequent review of the physician order and MAR by regional MDS leadership and interviews with staff confirmed that the resident’s anticonvulsant use should have been coded on the MDS and that the omission was an oversight.
A resident with dysphagia, hemiplegia, and hemiparesis following a cerebral infarction was receiving ordered enteral nutrition via feeding tube with documented administration on the MAR, but the quarterly MDS failed to code the presence of a feeding tube or percent of intake by artificial route. The nutrition section of the MDS was completed by the Dietary Manager instead of the MDS Coordinator, and facility staff acknowledged this resulted in erroneous MDS coding that did not accurately reflect the resident’s tube feeding status and intake.
The facility failed to accurately code MDS assessments for medications for two residents. One resident with bladder dysfunction and urinary retention was coded on a quarterly MDS as receiving an antibiotic during a seven-day assessment period, even though the MAR showed no antibiotic administration during that time, which the MDS coordinator later confirmed as an error. Another resident with dementia, psychotic disturbance, and PTSD was ordered Hydroxyzine 12.5 mg twice daily for anxiety, and the MAR showed it was given; however, the MDS nurse coded this as an antianxiety medication on the MDS, later acknowledging that Hydroxyzine is an antihistamine and that the antianxiety classification on the assessment was incorrect.
Multiple MDS assessments were inaccurately coded when one resident admitted with pneumonia and meningitis, who had documented IV access, midline catheter use, and IV ceftriaxone therapy, was not coded for IV access or IV antibiotics on the MDS. Another resident with Type 2 DM receiving subcutaneous Tirzepatide was incorrectly coded as having received an insulin injection after the MDS nurse mistakenly assumed Tirzepatide was insulin, despite no insulin being documented on the MAR. A third resident with anxiety disorder had multiple documented behaviors such as yelling, hitting, aggression, agitation, exit seeking, and refusing care during the MDS look-back period, but was coded as having no behaviors because the social work staff relied only on direct observation and did not review the electronic medical record for documented behaviors.
A resident with Alzheimer’s disease, heart failure, and dementia had three documented unwitnessed falls in her room, each assessed by nursing staff as causing no injury. However, the annual MDS was coded to show no falls since the prior assessment. The MDS Coordinator, who reviewed the fall event history and completed the assessment, later acknowledged that the MDS should have been coded to indicate two or more falls without injury. The DON and Administrator both stated that MDS assessments are expected to be accurate and that this resident’s fall history should have been correctly reflected on the annual MDS.
A resident with multiple comorbidities, including CHF and Alzheimer’s disease, was admitted with documented skin issues such as a dark spot on the coccyx, an open area on the spine, and knee redness. The care plan identified risk for skin breakdown and outlined general preventive skin care measures, but did not specifically address the documented open area or dark spot. The admission MDS inaccurately recorded that the resident had no pressure ulcers, scars over bony prominences, or other skin problems, and did not indicate the need for a pressure-relieving device, repositioning/turning program, or nutrition/hydration program for skin, resulting in an inaccurate MDS skin assessment.
The facility failed to accurately code MDS assessments for three residents in the areas of falls and restraints. Two residents with neurological and mobility-related diagnoses had multiple documented falls without injury shortly after admission, yet their admission or discharge MDS assessments were coded as having no falls or inaccurately reflected the number and type of falls. A third cognitively impaired resident with no physician orders for restraints was incorrectly coded on a quarterly MDS as having a trunk restraint used less than daily, despite staff stating that no restraints were used. The MDS Coordinator acknowledged these errors as incorrect coding or oversight, while leadership stated they expected MDS assessments to be accurate and timely.
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