Failure to Accurately Complete MDS Nutritional Status for Resident Receiving PEG Tube Hydration
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) Nutritional Status section for a resident who was receiving additional fluid intake via a percutaneous endoscopic gastrostomy (PEG) tube. The resident, who had multiple diagnoses including paranoid schizophrenia, type 2 diabetes, major depression, personality disorder, hypertension, and osteomyelitis of the vertebra, was admitted and re-admitted to the facility and had physician orders for specific water flushes through the PEG tube for hydration and tube patency. Medical record reviews showed that the resident consistently received 200 ml to 400 ml of additional water per day via the PEG tube, as documented in the Medication Administration Record (MAR) over several months. Despite this, the quarterly MDS assessments did not reflect the resident's daily additional hydration in Section K (Swallowing/Nutrition Status), which is required to document the average fluid intake per day by tube feeding. The dietician confirmed that Section K was not coded to show the percentage of additional water intake the resident was receiving per PEG tube, even though the Resident Assessment Instrument (RAI) Manual specifies the method for calculating and coding this information. This omission resulted in inaccurate completion of the MDS for the resident's nutritional status.