Inaccurate MDS Coding for Dialysis Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one resident, resulting in the submission of incorrect information to the federal database. Specifically, the MDS for a resident admitted with cystitis was marked to indicate that the resident was receiving dialysis, despite no physician orders for dialysis, no evidence of a dialysis graft, and direct statements from the resident and assigned nurse confirming that dialysis was not being provided. The MDS nurse acknowledged that the assessment was coded inaccurately and emphasized the importance of MDS accuracy for care planning and facility reimbursement. Interviews with the resident, the assigned licensed nurse, the MDS nurse, and the Director of Nursing all confirmed that the resident was not on dialysis. Review of facility policy and the CMS Resident Assessment Instrument User's Manual further supported the requirement for accurate MDS coding. The deficiency was identified through observation, interview, and record review, and was limited to one of seven sampled residents reviewed for MDS accuracy.