Inaccurate MDS Coding of Nutritional Status for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessment and coding of the swallowing and nutritional status for two residents, resulting in incorrect information being entered into their Minimum Data Set (MDS) assessments. For one resident with Alzheimer's disease and convulsions, the MDS indicated significant weight loss, while a review of the resident's weight records showed a substantial weight gain over both one- and six-month periods. The MDS nurse confirmed that the MDS should have been coded to reflect weight gain, not loss, and acknowledged the need for accurate reporting to CMS. Similarly, another resident with dysphagia and respiratory failure was incorrectly coded in the MDS as having experienced weight loss, despite weight records showing consistent weight gain during the relevant periods. The MDS coordinator admitted to not verifying the resident's weight records before entering data into the MDS, resulting in inaccurate assessment documentation. Both cases demonstrate failures in verifying and accurately recording resident assessment data as required by facility policy.