Failure to Accurately Code MDS for Tube Feeding
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for one resident who had a feeding tube in place. Despite clear documentation in the clinical record and physician orders indicating the resident was receiving enteral nutrition via a gastrostomy tube, five separate MDS assessments did not reflect the presence of the feeding tube or the percentage of nutritional and fluid intake provided by this artificial route. Observations confirmed the presence of a feeding pump at the resident's bedside, and interviews with the MDS nurse and registered dietitian (RD) revealed that the relevant MDS sections were either left blank or not coded, which was acknowledged as an error by the RD responsible for completing those sections. The resident in question had diagnoses including aphasia and dysphagia following a cerebral infarction, and had been on tube feeding since admission. The facility's documentation and staff interviews confirmed that the resident was receiving a prescribed formula via enteral pump for a specified number of hours each day. However, the MDS assessments failed to capture this information in Section K0520B (nutritional approaches), K0710A (proportion of total calories received through tube feeding), and K0710B (average fluid intake per day by tube feeding), resulting in inaccurate assessments that did not reflect the resident's actual nutritional status.