Inaccurate Coding of Resident Assessments
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for two residents. For one resident who began hospice services, the quarterly Minimum Data Set (MDS) assessment did not reflect their hospice status, despite documentation in the hospice contract and care plan indicating ongoing hospice care. The MDS coordinator confirmed that the assessment was coded incorrectly. For another resident requiring dialysis three times a week due to renal failure, the annual MDS assessment inaccurately indicated that the resident had not received dialysis in the facility during the assessment period, despite care plans and physician orders confirming regular dialysis treatments. The MDS coordinator acknowledged the inaccuracy in the assessment coding for this resident as well.