Inaccurate MDS Coding for Dialysis and Hospice Care
Penalty
Summary
The facility failed to accurately code a significant change Minimum Data Set (MDS) assessment for a resident with a history of cerebral vascular accident and dementia. The MDS assessment incorrectly indicated that the resident was receiving dialysis treatments and was on hospice care, despite the resident not having a history of dialysis and not currently being on hospice. The resident was, in fact, receiving palliative care for pain management, and her previous hospice care had been discontinued in 2022. The assessment also failed to indicate that the resident did not have a condition or chronic disease likely to result in a life expectancy of less than six months. Interviews with the resident confirmed she had never received dialysis and was not on hospice care at the time of the assessment. The MDS Coordinator, who was not employed at the facility when the assessment was completed, acknowledged that the resident should not have been coded for hospice or dialysis and attributed the errors to a keying mistake. Both the Director of Nursing and the Administrator stated their expectations that MDS assessments be coded accurately to reflect each resident's actual condition.