Failure to Accurately Code Indwelling Catheter on MDS Assessment
Penalty
Summary
The facility failed to accurately code a resident's Minimum Data Set (MDS) assessment regarding the presence of an indwelling catheter during the required look-back period. The MDS, completed and signed by the MDS Coordinator, did not indicate the presence of an indwelling catheter, external catheter, ostomy, or intermittent catheterization, despite the resident having physician orders for catheter care, documentation in the care plan, and multiple staff interviews confirming the ongoing use of a Foley catheter. The resident had documented diagnoses of benign prostatic hyperplasia, obstructive uropathy, and renal insufficiency, all of which are relevant to the use of a catheter. Electronic Health Record (EHR) review showed active orders for catheter changes, bag changes, irrigation, and output monitoring, all of which were reviewed and signed by the physician. Staff interviews with CNAs and an RN consistently confirmed the resident had a Foley catheter in place, with no indication it had been removed. The MDS Coordinator acknowledged responsibility for the assessment and admitted to failing to code the indwelling catheter, despite following the RAI manual. The deficiency was identified through review of the EHR, care plan, and staff interviews, which all contradicted the information recorded in the MDS.