Inaccurate MDS Coding for Resident's Eating Assistance
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for a resident. The MDS is a federally mandated assessment tool used to determine a resident's care needs and to develop an appropriate care plan. In this case, the quarterly MDS assessment for a resident was coded as requiring only setup or clean-up assistance for eating, which means the resident was believed to need help only before or after eating, but not during the activity itself. However, multiple sources of information indicated that the resident actually required more extensive assistance. The resident's medical record included diagnoses such as unspecified dementia, mood disorder, vascular dementia, major depressive disorder, and mild cognitive impairment. Interviews with the resident's family member, the registered dietician, and the unit manager all confirmed that the resident needed to be physically fed by staff, as the resident was unable to feed themselves. The care plan also documented a need for 1:1 assistance with feeding, and the resident was listed among those requiring feeding assistance. Despite this, the MDS Coordinator based the assessment coding solely on documentation from the Geriatric Nursing Assistants (GNAs) and did not utilize other available sources such as direct observation, interviews with other staff, or therapy documentation. This resulted in the resident's MDS being inaccurately coded, failing to reflect the true level of assistance required for eating.