Inaccurate MDS Assessment Coding for Catheter Use
Penalty
Summary
The facility failed to ensure an accurate assessment was completed for one resident regarding the presence of an indwelling catheter. The Minimum Data Set (MDS) assessment for this resident was coded to indicate the presence of a catheter during the seven-day look-back period, despite no documentation in the progress notes, care plan, or physician orders supporting catheter use. The resident's order summary, spanning from admission to the current date, did not show any orders for catheter placement, and the care plan did not mention a catheter. Direct observation of the resident revealed no catheter in place, and both the resident and staff, including a certified nurse aide and an LPN, confirmed that the resident was incontinent and had never had a catheter. The Director of Nursing (DON) also confirmed that the resident never had a catheter and was unsure how the MDS was coded to indicate one. The DON acknowledged the inaccuracy after noticing the error on the facility's matrix document while preparing for the survey.