Inaccurate MDS Coding for Discharge and Dialysis
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for two residents in the areas of discharge and dialysis. For one resident, the discharge MDS assessment was completed and incorrectly indicated that the resident was discharged to the hospital. However, both the nurse's note and interviews with the responsible party and staff confirmed that the resident was actually discharged home. The MDS nurse acknowledged that the assessment was miscoded due to the resident leaving a day earlier than expected, leading to the use of an incorrect discharge code. For another resident with end stage renal disease, the admission MDS assessment did not reflect that the resident was receiving dialysis, despite a physician's order for regular dialysis treatments at an offsite clinic. The MDS Coordinator admitted awareness of the resident's dialysis and stated that the omission was an oversight. Both deficiencies were confirmed through record review and staff interviews.