Inaccurate MDS Coding for Tobacco Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident in the area of tobacco use. The resident, who had a diagnosis of bipolar disorder with manic delusions, was admitted to the facility and was documented in the care plan and observation records as a smoker who understood and followed the facility's smoking policy. However, the annual MDS assessment incorrectly indicated that the resident did not use tobacco. Staff interviews revealed that the MDS was completed by a nurse from the corporate office during the regular coordinator's absence, and both the Case Mix Coordinator and the DON confirmed that the resident was a smoker and should have been coded as such. The error was attributed to oversight during the assessment process.