Inaccurate MDS Coding for Dental and Hearing Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments were coded accurately for two residents in the areas of dental status and hearing. For one resident with a history of traumatic brain injury, the dental treatment record indicated the resident was fully edentulous, yet the annual MDS did not reflect this status. Direct observation confirmed the absence of natural teeth, and facility staff acknowledged the inaccuracy in the MDS coding for this resident. For another resident admitted with heart failure, the nursing admission evaluation documented poor hearing in both ears. However, the admission MDS indicated the resident's hearing was adequate. Observations showed that the resident could only hear when spoken to at close range and with increased volume, and the resident reported being unable to hear and needing hearing aids. Multiple staff members confirmed the need to speak loudly and closely for the resident to hear, and facility staff acknowledged the MDS was inaccurately coded regarding the resident's hearing status.