Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents. For one resident with intact cognition and a diagnosis of morbid obesity, the MDS incorrectly identified the administration of insulin when the resident was actually receiving Trulicity, a non-insulin injectable medication. The registered nurse responsible for the MDS confirmed that Trulicity was the only injectable medication administered during the assessment period and acknowledged that it was mistakenly coded as insulin. The facility was unable to provide a policy for MDS completion when requested. For another resident with diagnoses including cancer, atrial fibrillation, and generalized muscle weakness, the MDS assessment failed to document an active diagnosis of dysphagia, did not identify symptoms of a swallowing disorder, and did not indicate the need for supervision with eating, despite clear documentation in the medical record and care plan. The resident had a history of oropharyngeal dysphagia, a choking episode, and specific dietary and supervision orders. The nurse responsible for the MDS acknowledged that these items should have been coded and that accurate coding is important for updating the care plan and staff instructions.