Inaccurate MDS Coding for Dental Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded regarding the dental status of two residents. For one resident, observations revealed broken and missing teeth, but the significant change MDS assessment did not document the presence of obvious cavities or broken natural teeth. The resident's care plan had previously identified a risk for oral and dental problems due to missing teeth and a need for assistance with oral care. Staff interviews confirmed the presence of missing and broken teeth, which were not reflected in the MDS documentation. For another resident, observations during a meal showed that her upper dentures were very loose, frequently falling off her gums and requiring her to push them back with a spoon. Despite this, both the significant change and quarterly MDS assessments failed to document the issue of broken or loosely fitting dentures. The resident had a history of severe cognitive deficit, type 2 diabetes, and protein-calorie malnutrition. Staff interviews indicated that the loose denture had been a persistent problem, known to both staff and the resident's family, but not accurately coded in the MDS. The facility's DON acknowledged awareness of the issue but was unsure why the MDS was not completed correctly, despite the facility's use of the CMS RAI manual for assessment guidance.