Inaccurate MDS Coding for Urinary Continence
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the urinary continence status of a resident. According to the MDS instructions, urinary continence should be coded as 'not rated' if the resident had an indwelling catheter during the entire seven-day look-back period. The clinical record for a resident admitted with kidney failure, GERD, and high blood pressure showed that the resident had an indwelling catheter at the time of admission and throughout the assessment period. Despite this, the resident's admission and Medicare-5 day MDS assessments were incorrectly coded, with urinary continence marked as 'occasionally incontinent' and 'always incontinent' instead of 'not rated.' This coding error was confirmed by the Registered Nurse Assessment Coordinator during an interview, who acknowledged that the MDS assessments did not accurately reflect the resident's continence status as required.