Inaccurate MDS Coding for Nutritional Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to deficiencies in the assessment of their care needs. Resident R1, who has a tracheostomy, gastrostomy tube, and spastic quadriplegic cerebral palsy, was receiving continuous Jevity 1.5 tube feedings as per a physician's order. However, the MDS with an Assessment Reference Date (ARD) of 11/11/24 did not indicate the presence of a feeding tube in Section K0520B, which was confirmed as an error by the Director of Nursing during an interview. Resident R46, diagnosed with Alzheimer's Disease and diabetes, had no evidence of weight loss or gain in the last month or six months. Despite this, the MDS assessments with ARDs of 7/12/24, 9/10/24, and 12/09/24 were incorrectly coded to indicate weight loss and gain. This was verified by a Dietary Technician, who confirmed that the sections related to weight loss and gain were inaccurately coded for Resident R46.
Plan Of Correction
Residents R1 and R46 were reviewed, corrected and resubmitted for accuracy. The facility did a look back from 05/01/2024 to determine inaccurate coding in the MDS. All inaccurate MDS have been modified for accuracy and reviewed by the interdisciplinary team (IDT Team). IDT team has been educated on accurate MDS completion based on the RAI manual. Nursing home administrator, director of nursing or designee will audit 5 full MDS per week every week times 2 weeks and then 5 a month for the next 60 days thereafter. Facility will identify this as a focus area needing improvement and review at QAPI (Quality Assurance Improvement Plan).