Inaccurate MDS Coding for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident who had an indwelling urinary catheter. Specifically, the admission MDS for a female resident with chronic kidney disease, type 2 diabetes mellitus, fluid overload, dementia, and a urinary tract infection was coded as "Always urinary incontinent" in Section H (Bladder and Bowel), despite documentation and observation confirming the presence of an indwelling urinary catheter. According to MDS coding guidelines, the continence status should have been marked as "Not rated" when a urinary catheter is present. Interviews with the MDS nurse and the Director of Nursing confirmed that the incorrect coding was a mistake and acknowledged that it was the responsibility of the MDS nurse to ensure accurate assessments. The facility's policy on resident assessment requires that results be recorded to assure continued accuracy, which was not followed in this instance. The error was identified through record review, staff interviews, and direct observation of the resident and her catheter.