Inaccurate MDS Coding of Oral/Dental Status for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for two residents accurately reflected their oral and dental status. For one resident with diagnoses including Parkinson's disease, dementia, diabetes mellitus, and dysphagia, the MDS indicated no oral or dental issues, despite the resident stating difficulty chewing due to lack of natural teeth and broken dentures. Observation confirmed the resident was eating breakfast and expressed these concerns directly. The MDS nurse acknowledged that the MDS was incorrectly coded and did not reflect the resident's actual oral and dental condition. Similarly, another resident with dementia, diabetes mellitus, dysphagia, and muscle weakness was assessed in the MDS as having no oral or dental issues. However, during observation and interview, the resident reported having no natural teeth and experiencing difficulty chewing due to loose dentures. The MDS nurse confirmed that this resident's MDS was also inaccurately coded, failing to represent the true oral and dental status. The facility's policy required the interdisciplinary team to ensure MDS accuracy, but this process was not followed in these cases.