Inaccurate MDS Coding for Behavioral Symptoms and Mood
Summary
The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) assessments accurately reflected the behavioral and mood status of two residents with dementia and psychiatric diagnoses. For one resident with Alzheimer’s disease, anxiety, depression, and spastic hemiplegia, the admission MDS documented severely impaired cognition, total dependence in self-care and mobility, and no physical or verbal behavioral symptoms directed toward others. Despite this, multiple nursing progress notes around the time of admission described the resident as verbally and physically aggressive toward staff during ADL care, including striking at a CNA, attempting to hit, push, and grab staff, and being combative and refusing medications, weights, and care. An incident report and nursing note also documented that this resident slapped her roommate in the face, leading to separation of the residents and placement of the aggressive resident near the nurse’s station. These documented behaviors were not reflected in the admission MDS, and the triggered care areas did not include psychosocial well-being or behavioral symptoms directed toward others. The same resident’s care plan, initiated and revised shortly after admission, addressed cognitive impairment, impaired communication due to a language barrier, and potential adverse effects of antidepressant medications, but there was no documented review or revision of the care plan following the admission MDS assessment that had triggered care areas such as cognitive loss/dementia, communication, falls, and psychotropic drug use. Staff interviews corroborated that this resident was verbally and physically aggressive when she first arrived, often swinging at staff during care, and that she could be more agitated in the afternoons. CNAs, a medical assistant, and physical therapy staff all described a pattern of aggression and the need for de-escalation techniques and family involvement, yet these ongoing behaviors and related interventions were not captured in the MDS assessment or reflected in updated care planning tied to that assessment. For a second resident with Alzheimer’s disease, major depressive disorder, recurrent suicidal ideation, repeated falls, and a cognitive communication deficit, the quarterly and significant change MDS assessments documented severely impaired cognition, some need for help with self-care, independent mobility, and no physical or verbal behavioral symptoms directed toward others. However, facility records showed that this resident had a history of physically and verbally aggressive behavior, including cursing, yelling, throwing items, and a documented incident where she punched a roommate in the jaw during a dispute over a privacy curtain. An incident report described this resident as verbally and physically aggressive toward her roommate, resulting in a room change and notification of leadership and the physician. The resident’s care plan included a problem for physically abusive behavior with interventions such as room change, behavior documentation, and obtaining antianxiety medication, but the MDS did not reflect these behaviors. Additionally, this second resident experienced an episode of suicidal ideation when she reportedly stated she was going to kill herself while walking down the hallway. A nurse documented locating and assessing the resident, who then denied making the statement and denied suicidal ideation, intent, or plan. A psychiatric mental health nurse practitioner note on the same date recorded that the resident had been placed on 1:1 observation after voicing a desire to kill herself, that she later denied active or passive suicidal ideation, and that her sertraline dose was increased. Despite this episode and the implementation of psychotropic medication changes, the subsequent quarterly MDS did not accurately reflect Section D – Mood in relation to suicidal ideation, and there was no documented review or revision of the care plan addressing psychosocial well-being following this incident. Interviews with the regional nurse, MDS coordinator, ADON, senior director, and former administrator confirmed awareness of the resident-to-resident incidents and suicidal ideation, acknowledged that IDT meetings occurred and interventions were implemented, and attributed the lack of MDS updates to staff turnover, documentation errors, and failure to revise assessments as required by facility policy and the RAI Manual. The facility’s own MDS 3.0 Completion policy stated that residents are to be comprehensively assessed to identify care needs and develop an interdisciplinary care plan, and that a Significant Change in Status Assessment must be completed within 14 days of identifying a qualifying status change. Leadership interviews indicated that changes in cognition, ADLs, behavior, and psych interventions or medications could constitute a significant change, yet the behavioral aggression and suicidal ideation episodes for these two residents were not incorporated into updated MDS assessments. As a result, the assessments did not accurately reflect the residents’ physical and verbal behavioral symptoms directed toward others or mood status, despite clear documentation of these issues in progress notes, incident reports, psychiatric evaluations, and staff interviews.
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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