Failure to Accurately Code Significant Weight Loss on MDS Assessment
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) Assessment was completed accurately for a resident with significant weight loss. The resident, who had diagnoses including dementia, diabetes mellitus, and dysphagia, was documented as having severe cognitive impairment and requiring setup assistance for eating. The Annual MDS Assessment recorded the resident's weight as 179 pounds with no weight loss, while the subsequent Quarterly MDS Assessment listed the weight as 132 pounds, also indicating no weight loss. However, clinical records showed the resident's weight dropped from 179.3 pounds to 131.7 pounds between assessments, representing a 26.55% loss, and further decreased to 123.3 pounds, totaling a 31.23% loss since the initial weight. Staff interviews confirmed the weight loss should have been coded on the MDS, but it was not, despite facility policy to follow the Resident Assessment Instrument (RAI) Manual for MDS coding.