Inaccurate MDS Documentation for Residents
Summary
During a Recertification Survey, the facility was found to have deficiencies in accurately reflecting residents' statuses in their assessments. Specifically, the Minimum Data Set (MDS) 3.0 assessment for two residents was inaccurate. One resident, who had a history of wandering behavior and was observed with a Wanderguard on multiple occasions, was documented in the MDS as not using a Wander/elopement alarm. This discrepancy was noted despite the resident's care plan and physician orders indicating the use of a Wanderguard. Another resident, who was admitted with a diagnosis affecting their ability to communicate, was inaccurately documented in the MDS as having clear speech and the ability to make themselves understood. Observations showed the resident using gestures to communicate due to slurred speech, and staff confirmed the resident's nonverbal status. The MDS Coordinator acknowledged the inaccuracies but could not explain the errors as the responsible MDS Assessor was on medical leave. The Director of Nursing stated that the Nursing Department collaborates with the MDS Department to ensure the accuracy of MDS documentation.
Plan Of Correction
Plan of Correction: Approved January 31, 2025 F 641 483.20 Accuracy of Assessment SS=D I. The following actions were accomplished for the resident(s) identified in the sample: The DNS reeducated the MDS Coordinator submitted a correction of the MDS for Resident #36 and #6 on 1/7/2025. The DNS reeducated the MDS Coordinator regarding responsibilities to ensure the accuracy of MDS data prior to submission. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have the potential to be affected by the same practice. The MDS Coordinator/Designee will review assessments, progress notes, and plan of care to ensure accuracy of MDS completion prior to submission. The MDS Coordinator will review the last submitted MDS assessment for all residents to ensure the assessment accurately reflects the resident's status at the time the assessment was completed. A correction MDS will be submitted as needed. III. The following system changes will be implemented to ensure continuing compliance with regulations: The MDS Coordinator/Designee will develop an audit tool to review all scheduled MDS for accuracy prior to submission. The audit tool will assess residents' plan of care, progress notes, and assessment to ensure accuracy and the same practice does not recur. The Administrator, DNS, and MDS Coordinator reviewed the policy and procedure entitled "Minimum Data Set Assessment Completion." No revision is needed at this time. The DNS/Designee will provide education to the MDS Coordinator regarding the above protocol emphasizing the importance of the MDS including accurate data assessment to ensure the CCP addresses each resident's strengths, care needs, including the use of wander alert devices and resident communication ability as applicable. All IDCPT members responsible for completing sections of the Residents Assessment Instrument (RAI) will be provided with this education and training. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The MDS Coordinator/Designee will monitor the same practice does not recur through weekly audits of scheduled MDS. The audit tool will be utilized to ensure the MDS is accurate prior to submission and monitor compliance with accuracy of MDS data. The audit will occur weekly for six months or until two quarters are at 100% compliance. The RN/MDS Coordinator will audit 15% of completed MDS assessments monthly for six months. All MDS accuracy audit findings will be reported to the Administrator and DNS on a monthly basis. Corrective actions, such as submitting a correction MDS, will be implemented as indicated. The MDS Coordinator will report MDS accuracy audit findings to the QAPI Committee for six months. Responsible: The MDS Coordinator/Designee is responsible to ensure regulation compliance.
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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