Inaccurate MDS Assessments for Residents
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in their discharge statuses and care plans. Resident #107 was inaccurately recorded as being discharged to a hospital, while the Post-Discharge Plan of Care indicated a discharge to home with home health services. Interviews with the MDS Nurse, Director of Nursing (DON), and Administrator confirmed the error, acknowledging that the MDS was incorrectly coded and did not reflect the resident's actual discharge status. Resident #106's MDS inaccurately documented a discharge to home/community, despite the resident being sent to a hospital due to breathing difficulties. The physician's order and progress notes confirmed the hospital discharge, but the MDS was signed off as accurate by LVN Manager #2, who later admitted the error. Both the MDS Nurse and the DON emphasized the expectation for MDS accuracy, which was not met in this instance. Resident #61's quarterly MDS assessments failed to indicate the use of a WanderGuard device, despite orders and care plans specifying its necessity due to the resident's risk of elopement. The device was ordered to be checked regularly, yet this was not reflected in the MDS. Interviews with the MDS Nurse and DON highlighted the oversight, with the DON reiterating the need for MDS assessments to accurately reflect the resident's condition and care requirements.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The MDS coding for Resident #107 has been corrected to accurately reflect that the resident discharged home from the facility on 3/07/25. The MDS updated coding for Resident #106 on 3/07/25 to correctly indicate the resident discharged to a hospital. The MDS coding for Resident #61 has been revised on 3/07/25 to ensure accurate documentation of the WanderGuard assessments. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents may potentially be impacted by this deficient practice. MDS Regional completed the review on 3/7-3/10/25 of all residents who had discharged assessment completed in the last 90 days for accuracy to ensure that assessments reflect the correct discharged status, and no residents' assessments were identified with the same deficient practice. RAI specialist completed the review on 3/26/25 of MDS assessments of all residents currently with a Wanderguard order; to verify coding accuracy of Wanderguard on section P and no other residents' assessments were identified with incorrect coding. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: On March 19, 2025, an informative in-service training session was conducted specifically for the two MDS nurses at the facility. The primary objective of this in-service was to provide comprehensive reeducation on the critical importance of accurately coding Minimum Data Set (MDS) assessments. This training emphasized how precise MDS coding can significantly affect the quality of patient care and overall healthcare outcomes for residents. Lead MDS Nurse will cross-check all MDS completed to ensure accuracy of coding before letting the MDS regional know for a second review and signing of the MDS for completion and accuracy. The Regional Resident Assessment Instrument (RAI) Specialist, and MDS Coordinator developed a quarterly training program for the facility MDS Coordinators that complete MDS's for coding accuracy. RAI Specialist will complete a monthly MDS audit for accuracy to ensure compliance and that resident conditions are accurately captured on each MDS assessment. The results will be sent to the facility MDS, Admin, and DON. Any inaccuracies or coding errors will be discussed with the MDS, and follow-up training will be scheduled as needed. Ongoing training sessions will be organized for MDS nurses and relevant staff to reinforce best practices in coding, ensuring they stay updated on any changes in regulations or procedures. This commitment to continuous education will help maintain high standards of coding practice. How the facility plans to monitor its performance to make sure that solutions are sustained: QAPI will review monthly audits performed by the Regional RAI specialist for accuracy, completeness, and thoroughness. Include dates when corrective actions will be completed: March 19, 2025
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 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 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.
Inaccurate MDS coding affected two residents. One resident’s PASARR Level II status was coded inconsistently with the record, and another resident’s MDS failed to code an antidepressant on Item N0415 even though the resident was receiving Trazodone for insomnia and had diagnoses including schizoaffective disorder, major depressive disorder, and anxiety.
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.
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).
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.
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 PASARR Status and Antidepressant Use
Penalty
Summary
The facility failed to ensure the accuracy of the MDS assessment for 2 of 24 residents reviewed for MDS accuracy. For Resident 64, the clinical record showed diagnoses including anxiety and bipolar disorder, and a PASARR dated 5/8/23 indicated a Level II screening. However, the annual MDS assessment dated 1/30/26 stated the resident was not currently considered by the State to have a Level II PASARR screening, which was inconsistent with the PASARR information in the record. For Resident 9, the clinical record included diagnoses of schizoaffective disorder, major depressive disorder, and generalized anxiety disorder. A physician order dated 6/26/25 showed Trazodone HCl 25 mg by mouth at bedtime for insomnia, but the quarterly MDS assessment dated 2/18/26 did not indicate the resident received an antidepressant medication on Item N0415. The RAI Manual stated medications are to be coded in Item N0415 according to therapeutic category and/or pharmacological classification, and the MDS Coordinator acknowledged the resident was taking an antidepressant at the time of the assessment and that Item N0415C1 should have been coded yes.
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