Inaccurate Resident Assessments in MDS Documentation
Summary
The facility failed to ensure accurate assessments for four residents during a recertification survey. For three residents, antiviral medications were incorrectly documented as antibiotics in the Minimum Data Set (MDS) assessments. This error was attributed to the electronic medical record system, which automatically classified antivirals as antibiotics. Interviews with the Nurse Unit Manager, MDS Coordinator, and Director of Nursing revealed a misunderstanding of the classification of antiviral medications, which was not aligned with the Resident Assessment Instrument manual or Centers for Medicare and Medicaid Services guidelines. Additionally, the assessment for another resident inaccurately documented a diagnosis of Non-Alzheimer's Dementia, despite the resident having no such diagnosis in their medical records. The resident was noted to have mild cognitive impairment but was alert and oriented. The error was made by the Nurse Unit Manager, who checked off the dementia diagnosis in the MDS assessment. Interviews with the Physician Assistant and Director of Nursing confirmed the absence of a dementia diagnosis in the resident's medical records.
Plan Of Correction
Plan of Correction: Approved January 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action: -The MDS coordinator on 12/06/2024 corrected immediately the deficiencies identified to accurately reflect the residents’ clinical diagnoses. The antibiotic checkbox was unticked for Resident #1, Resident #36, and Resident #42, and the corrected MDS was re-submitted to CMS. The MDS for the affected resident #54 was also immediately reviewed, corrected to remove the non-Alzheimer’s dementia diagnosis, and re-submitted to CMS. The error did not affect the residents’ quality of care at the facility. -The DON on 12/06/2024 held an IDT team huddle with the facility’s physician, physician assistant #1, unit RN managers, and individually informed the affected residents of the coding error and the corrective actions taken. -The IDT team from 12/06/2024 to 12/11/2024 performed due diligence in assuring that no care plan changes or interventions were affected by the incorrect coding, and no adverse impact occurred. No additional residents were inaccurately documented during the prior MDS submissions from 08/2024 to 11/2024. -The Compliance team on 12/12/2024 reviewed the facility’s Minimum Data Set Functional Coding Policy. No amendments were needed. Identification of Others Potentially Affected: -The facility respectfully submits all residents were potentially affected by this practice, after reviewing MDS records. System Changes to Prevent Recurrence: -The MDS coordinator was re-in-serviced on proper Section N (Medications) coding procedures, emphasizing accuracy and review processes. Training included the importance of cross-referencing the MAR indicated [REDACTED] facilitated by the compliance officer. In addition, training was also provided for proper coding for Section I (Active Diagnoses), including verifying [DIAGNOSES REDACTED] resident’s medical record before coding. -Subsequent to a root cause analysis, the Administrator contacted the MDS software vendor on 12/10/2024 to address the automated logic or interface issues causing incorrect antibiotic selection. Thus, implementing software updates or adjustments to prevent related errors. -The DON on 12/10/2024 instituted a secondary review process for all MDS submissions: A designated staff member (Senior RN Manager or ADON) will verify accuracy before all submission. Quality Assurance Monitoring: -The DON will conduct weekly audits of 10% of MDS submissions for the next 90 days to ensure accuracy in functional coding, with special focus on Section I and Section N. Findings will be reviewed during monthly QA meetings, and adjustments to processes will be made as necessary. -The Performance Metrics is set at a goal of 100% compliance with accurate MDS coding. Any errors identified during audits will be addressed immediately. -Audit tool has been created and implemented for ongoing monitoring. Responsible Party: Minimum Data Set Coordinator
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
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 was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
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.
Inaccurate MDS Coding for Insulin: A resident’s quarterly MDS was coded to show insulin use during the lookback period, but review of the physician’s orders and MAR found no evidence the resident received insulin. An LPN confirmed the assessment was coded inaccurately.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Inaccurate MDS Coding for Diabetes Medication
Penalty
Summary
The facility failed to accurately code medication on the Minimum Data Set (MDS) assessment for 1 resident who was reported to be receiving insulin. The resident had a diagnosis of diabetes, and the quarterly MDS assessments accepted on 2/3/26 and 4/15/26 identified that the resident received an insulin injection 1 time during the last 7 days. However, the resident’s current physician orders showed no insulin orders. Instead, the orders included semaglutide, with instructions for a weekly subcutaneous injection on Wednesdays for diabetes with hyperglycemia, beginning at 0.25 mg and then increasing to 0.5 mg. During interview, the resident stated she did not receive insulin and instead received a weekly GLP-1 injection on Wednesdays. The RN confirmed she had incorrectly coded both quarterly MDS assessments as the resident receiving no insulin and stated she would need to complete and submit a modification of the assessment. The DON stated she would expect the MDS to be accurate and reflect each resident’s status.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
MDS Incorrectly Omitted BiPAP Use
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for one resident who used a non-invasive ventilatory device. The resident’s quarterly MDS dated [DATE] identified intact cognition with no hallucinations or delusions, but in Section O, the item for non-invasive mechanical ventilator use, including BiPAP and CPAP, was not checked, and Section Z1, “none of the above,” was marked instead. During observation, a BiPAP machine was seen on the resident’s bedside table with a gallon of water next to it, and the resident stated staff assisted with the machine at night. The resident later stated she had previously used CPAP and had been changed to BiPAP. The medical record included an order to resume CPAP with home settings and an after-visit summary documenting BiPAP home use with specified pressure settings for obstructive sleep apnea. An LPN stated staff assisted the resident with a CPAP machine, and the MDS coordinator confirmed the quarterly MDS was coded incorrectly because the resident did use a non-invasive ventilatory device.
Inaccurate MDS Coding for Code Alert Devices
Penalty
Summary
The facility failed to ensure accurate MDS coding for the use of code alert devices for 14 of 14 residents identified as at risk for elopement and wandering. The code alert system log titled Wander Guard Monitor for 4/2026 identified residents R3, R4, R12, R13, R17, R18, R19, R22, R25, R28, R32, R34, R37, and R46 as having a code alert device in use, but their MDS assessments did not consistently reflect that information in Section P. Instead, the assessments frequently indicated that a wander guard alarm was not in use and that the residents had not exhibited wandering behavior. Several resident records also lacked corresponding care plan interventions for elopement and wandering. R3, R4, R18, R22, R28, R32, R34, R37, and R46 had care plans that did not include elopement or wandering interventions, and R22's care plan did not identify the placement location of the code alert device. R37's problem area for elopement was not initiated until 5/1/26. R46 was discharged on 4/20/26, and the care plan was requested but not received. R19's most recent elopement assessment identified low risk and included clothing labeled with identification and an identification band, but did not select the door alarm band applied as an intervention. R12's assessments similarly identified low risk and listed clothing labeling and an identification band, but did not select the door alarm band applied. The record also showed inconsistencies between assessments, documentation, and staff statements. R13 and R17 had elopement assessments completed on 5/1/26 and their code alert devices were removed, while R19's EMR lacked evidence that elopement assessments were completed quarterly. R12's EMR lacked evidence of quarterly elopement assessments, and progress notes stated the assessments were reviewed with no change despite later documentation of a successful exit of the building and attempts to exit. During interviews, staff stated that residents with wandering or elopement risks should be identified on the care plan, that code alert devices were kept in a book at the main entrance desk, and that the MDS should be coded to reflect code alert placement because it drives care and the care plan.
Inaccurate MDS Coding for Insulin
Penalty
Summary
Resident 2’s quarterly MDS dated March 22, 2026, was coded to indicate that the resident received insulin on one day in the last seven days in section N0350. However, review of the physician’s orders and the MAR showed no evidence that the resident received insulin during the assessment lookback period. During interview on April 23, 2026, at 1:35 p.m., licensed staff E4 confirmed that the assessment was coded inaccurately.
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