Inaccurate MDS Coding for Resident Discharges
Penalty
Summary
The facility failed to ensure the comprehensive Minimum Data Set (MDS) assessments were accurately coded for two residents. Resident #108 was admitted with diagnoses including Type 2 diabetes without complications and acute failure with major recurrent, moderate. The MDS for Resident #108 inaccurately indicated a discharge to home/community, while the resident was actually transferred to the hospital for further evaluation and treatment due to increased no output. This discrepancy was identified through a review of the resident's records. Similarly, Resident #110, who was admitted with acute failure and Type 2 diabetes without complications, was inaccurately coded in the MDS as being discharged to a short-term general hospital. However, the discharge summary revealed that Resident #110 was discharged home in stable condition with his daughter. Interviews with the MDS Coordinator and the Director of Nurses confirmed the inaccuracies in the MDS coding for both residents. The facility did not have a specific policy to address this issue, relying instead on the Resident Assessment Instrument (RAI) to ensure accurate MDS coding.
Plan Of Correction
Resident (#108) and Resident (#110) Minimum Data Sets were modified to reflect the accurate discharge status. Residents that were discharged from the facility have the potential to be affected. Residents discharged from the facility in the last 30 days were reviewed by the Minimum Data Set coordinator/ designee to ensure accurate coding of the discharge on the minimum data set. Those found to be inaccurate will be modified to accurately reflect the residents discharge location. The Director of Nursing/Designee provided education to the Minimum Data Set coordinators, Case Manager and Social Service Director on the process for identifying the discharge location and accurate coding of the Minimum Data Set. The Director of Nursing/Designee will complete 3 random weekly audits on discharged residents to ensure residents discharged status was coded accurately. Results of the audits will be tracked and trended and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance achieved.