Failure to Accurately Code MDS Assessment for Neurogenic Bladder Diagnosis
Penalty
Summary
The facility failed to accurately code a Minimum Data Set (MDS) assessment for a resident who had a diagnosis of neurogenic bladder and an indwelling urinary catheter. The resident was admitted with multiple diagnoses, including neuromuscular dysfunction of the bladder, and had a physician order for a catheter due to neurogenic bladder. However, the quarterly MDS assessment did not reflect the diagnosis of neurogenic bladder in section I, despite the presence of supporting documentation in the resident's medical record and physician orders. Interviews with facility staff revealed that the MDS nurse typically relies on information pulled from various sources, such as nurse practitioner notes and hospital discharge summaries, and does not routinely review physician orders, assuming the system will automatically import relevant diagnoses. Both the MDS nurse and the DON acknowledged that the diagnosis of neurogenic bladder should have been included in the MDS assessment, and the administrator confirmed the expectation that MDS assessments accurately reflect each resident's diagnoses and care needs.