Inaccurate MDS Coding of MDRO Status
Penalty
Summary
The facility failed to accurately complete the quarterly Minimum Data Set (MDS) for one resident, resulting in an inaccurate record regarding the resident's Multi-Drug Resistant Organism (MDRO) status. The resident was admitted with diagnoses including diabetes mellitus, peripheral vascular disease, and resistance to multiple antimicrobial drugs. The MDS indicated the presence of an active MDRO diagnosis, but a review of the resident's transfer form, hospitalization record, and microbiology cultures showed no evidence of MDRO or need for isolation. The microbiology cultures specifically indicated a urinary infection with bacteria sensitive to multiple antibiotics, confirming the absence of MDRO. Observations revealed that there was no signage for contact-based precautions in the resident's room, and interviews with facility staff confirmed that the MDRO status was incorrectly marked on the MDS when laboratory results were still pending. Staff acknowledged that the MDS should have been updated once the lab results confirmed the absence of MDRO. The Director of Nursing also stated that the MDRO status should have been coded accurately and verified, and noted the absence of a facility policy specific to MDS completion.