Failure to Accurately Code MDS Assessment for Diuretic Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident in the area of medications. The resident, who had diagnoses including hypertension and heart failure, was admitted with a care plan that included diuretic therapy and had a physician's order for daily Bumetanide, a diuretic, for edema. Medication Administration Records confirmed that the diuretic was administered daily during the relevant period, and the MDS Coordinator acknowledged that the resident received the medication during the seven-day look-back period for the quarterly MDS assessment. However, the MDS assessment was not coded to reflect the resident's receipt of diuretics, which was attributed to an oversight by the MDS nurse. The Administrator also confirmed that the MDS should have been coded accurately for diuretic use.