A resident receiving dialysis three times weekly was not coded for dialysis in Section O on two quarterly MDS assessments. The MDS Nurse confirmed the resident attended all scheduled dialysis treatments but did not code them because dialysis center communication sheets were unavailable during the look-back period. The resident had ESRD and dependence on renal dialysis, and the ADM stated the MDS should accurately reflect dialysis services.
Inaccurate MDS Bladder Assessment: A resident’s MDS failed to document an indwelling urinary catheter in Section H even though observation and the TAR showed a catheter and catheter bag order in place. The MDS nurse confirmed the assessment error, and the resident had diagnoses including diverticulosis and a stage 3 sacral pressure ulcer, with BIMS indicating cognitive intactness.
A resident with Alzheimer's disease was inaccurately coded on the MDS as using bed rails as restraints, despite facility documentation and staff interviews confirming that the side rails were used for mobility and bed boundary purposes and were not considered restraints.
The facility did not accurately complete MDS sections for four residents, including failing to document hospice services for two residents on hospice and incorrectly coding two residents as having bipolar disorder without supporting diagnoses. These errors were confirmed by the DON through record review and staff interviews.
A resident with a history of Parkinson's Disease and Schizophrenia, who was confirmed by staff to be blind and observed bumping into objects, was inaccurately documented as having adequate vision on the MDS assessment. Despite staff awareness and supporting documentation of the resident's blindness, the MDS and care plan did not reflect the true vision status.
The facility failed to accurately code MDS assessments for several residents, incorrectly marking antiplatelet medications as anticoagulants and failing to identify a resident's serious mental illness as documented by PASRR. These errors were confirmed through record reviews and staff interviews, revealing a lack of adherence to proper assessment protocols.
The facility failed to accurately code MDS assessments for multiple residents, incorrectly documenting the administration of anticoagulant, antiplatelet, and hypnotic medications. Despite residents receiving antiplatelet and hypnotic drugs, the MDS reflected administration of anticoagulants or omitted the correct drug classes. Staff interviews confirmed the errors were due to inaccurate review and coding of medical records, and there was no triple-check system in place to verify MDS accuracy.
A resident with severe cognitive impairment and a history of cerebral hemorrhage was incorrectly coded on the admission MDS as having bed rails used as a restraint, despite documentation and staff interviews confirming the rails were for positioning and bed mobility. Facility staff acknowledged the coding error after review and observation.
A resident with dementia was incorrectly coded on the MDS as having a limb restraint, despite no documentation or evidence of restraint use. Staff interviews and record reviews confirmed the error, which was acknowledged by the LPN who completed the assessment and the DON. The facility's policy requires accurate assessments, but this was not met in this case.
A resident's MDS assessment was inaccurately coded to indicate receipt of an anticoagulant, when the only relevant medication prescribed was aspirin for hypertension. Staff confirmed that aspirin, an antiplatelet, was incorrectly coded as an anticoagulant, contrary to facility policy and the RAI Manual.
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