Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for three residents, resulting in assessments that did not reflect the residents' actual status at the time of completion. For one resident, the admission MDS was incorrectly coded to indicate the resident was not receiving hospice services, despite census documentation and the care plan confirming hospice care at admission. Both the RN and DON acknowledged that the MDS should have reflected hospice services. Another resident's quarterly MDS was marked as having a colostomy in Section H, but interviews with nursing staff confirmed the resident did not have a colostomy, and the MDS nurse admitted this was an error. A third resident's quarterly MDS indicated no use of mobility devices, despite the resident having a history of lower limb amputation and being observed with a wheelchair and prosthetic leg in the room. The resident confirmed using these devices when out of bed, and the MDS coordinator acknowledged the MDS was inaccurate. The DON confirmed the expectation that MDS reports should accurately reflect the resident's status and that the MDS in question was not accurate regarding mobility devices. These findings were based on record review, staff interviews, and direct observation.