Inaccurate MDS Coding for Hospice Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for a resident with a history of congestive heart failure, chronic kidney disease stage 3, and an automatic cardiac defibrillator. The resident was admitted without hospice or dialysis services, later placed on hospice, and never received dialysis. However, a review of the MDS Section O dated January 22, 2025, incorrectly indicated the resident was on dialysis, despite documentation and staff interviews confirming the resident was only on hospice care at that time. The MDS Nurse acknowledged the error, stating the resident was never on dialysis and that the assessment should have reflected hospice care. The Director of Nursing also confirmed that the MDS should have been coded to match the resident's actual status. Facility policy requires that MDS assessments accurately reflect information in progress notes, care plans, and resident observations, which was not followed in this instance.